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S.Sudan rivals seal security pact in peace 'milestone ' | Hi, what are you looking for?
President Salva Kiir and his rival, Vice President Riek Machar, agreed on the creation of a unified armed forces command.
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In what has been hailed as a major breakthrough, South Sudan’ s rival leaders sealed an agreement Sunday on a key military provision of their stuttering peace deal.
President Salva Kiir and his rival, Vice President Riek Machar, agreed on the creation of a unified armed forces command, one of several crucial unresolved issues holding up implementation of the 2018 deal to end the country’ s bloody five-year civil war.
“ Peace is about security and today we have ( achieved) a milestone, ” said Martin Abucha, who signed the agreement on behalf of Machar’ s opposition SPLM/A-IO.
Minister of presidential affairs Barnaba Marial Benjamin hailed the deal — signed following mediation by neighbouring Sudan — as a “ necessary step… that opens a route for the stable government of the Republic of South Sudan ”.
Tensions between forces loyal to Kiir and former rebel leader Machar have spiralled recently, triggering fears in the international community of a return to full-blown conflict in the world’ s youngest nation.
Both men were at the ceremony in the capital Juba for the signing of the accord, which stipulates a 60-40 distribution in favour of Kiir’ s side of key leadership posts in the army, police and national security forces.
Mohamed Hamdan Daglo, the number two in Sudan’ s post-coup ruling council, had arrived in Juba on Friday in a bid to break the deadlock over the security arrangements.
Sudan, one of the guarantors of the 2018 deal, drew up the proposal after Kiir on March 25 issued a presidential decree on the formation of the military command structure, a move that had been swiftly rejected by Machar as a “ unilateral ” action.
Landlocked South Sudan, one of the poorest countries on the planet despite large oil reserves, has suffered from chronic instability since it declared independence from Sudan in 2011, spending almost half of its life as a nation at war.
It has struggled to draw a line under the 2013-2018 conflict that erupted after Kiir accused Machar of an attempted coup. Almost 400,000 people lost their lives and millions more were displaced by the fighting.
– UN warning of potential ‘ catastrophe’ –
Although the two men formed a power-sharing unity government more than two years ago, South Sudan has continued to lurch from crisis to crisis, battling flooding, hunger, violence and political bickering that threatened to undo even the limited progress in the faltering peace process.
The fragile peacemaking was put under further pressure last month when Machar’ s Sudan People’ s Liberation Movement in Opposition ( SPLM/A-IO) pulled out of a body monitoring the process to protest at continued “ unprovoked ” attacks of its bases by its “ peace partner ”.
The United States last week expressed concern over the growing tensions, deploring reported clashes in Upper Nile State and warning that the opposition move undermined the peace agreement.
Last month, the UN Security Council voted to prolong its peacekeeping mission in South Sudan for one more year, although Russia and China abstained.
The operation, with up to 17,000 soldiers and 2,100 police officers, is one of the most expensive for the UN, with an annual budget surpassing $ 1 billion.
In a presentation to the Security Council, the UN envoy for South Sudan, Nicholas Haysam, issued a stark warning to the country’ s leaders to do more to prepare for elections due to be held in less than a year.
“ Elections have the potential to be a nation-building moment, or a catastrophe, ” he said.
Although he highlighted progress in some areas including the operation of key government institutions and parliament, other issues are stalled, including the process of drafting a new constitution.
The UN has repeatedly criticised South Sudan’ s leadership for its role in stoking violence, cracking down on political freedoms and plundering public coffers.
South Sudan also faces humanitarian woes caused by conflict as well as climate-related disasters such as flooding and drought, prompting the UN on Thursday to launch a $ 1.6 billion aid plan.
It said the funding will be used to provide urgent life-saving assistance and protection in a country where it is estimated more than two thirds of the population, nearly nine million people, require aid relief.
With 2,400 staff representing 100 different nationalities, AFP covers the world as a leading global news agency. AFP provides fast, comprehensive and verified coverage of the issues affecting our daily lives.
Under a shattered crescent hanger at Ukraine's Gostomel Airport the world's largest plane lies buckled and broken.
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Schools in Iran to fully reopen tomorrow | The Iranian education ministery has said that all the schools in the country will re-open on Sunday after the end of the Nowruz holidays, Trend reports citing Mehr News Agency.
The Spokesman for the Ministry of Education, Sadegh Sattarifard said on Saturday that all the schools across the country will re-open tomorrow as the Covid-19-related restrictions in Iran have been lifted.
The spokesman said that all the schools will have to reopen on Sunday and every student that does not attend the classes will be considered as absent on that day from now on.
This is while, the Iranian health ministry recently said that more than 26 million in Iran have received 3 doses of anti-coronavirus vaccines.
The number of cases with the Covid-19 as well as the daily death toll have been declining from a sixth wave of the contagious disease.
The health ministry only reported 37 death from Covid on Saturday and nearly 1,887 new cases of the infection.
So far, 63,935,082 people have received the first dose, 56,906,191 people have received the second dose, and 26,252,08 people have received the third dose of anti-Coronavirus vaccines, the ministry said on Saturday.
A total 147,093,281 doses of the vaccine have been administered in the country so far. | general |
COVID-19 on decline in Denmark: SSI study | The results of an ongoing study of blood donors confirm that the COVID-19 pandemic is on the decline in Denmark, the Statens Serum Institut ( SSI), the country's leading infectious diseases agency, said in a press release on Friday, Trend reports citing Xinhua.
The SSI has registered a `` clear decrease '' in the number of new infections in recent weeks, the institute's Director, Henrik Ullum, said. `` This is gratifying and it shows that Denmark, due to its high levels of population immunity from both vaccines and infections, is in a good place right now against the threat of COVID-19. ''
According to the SSI, recent analyses of blood samples have shown that up to 70 percent of Denmark's adult population ( aged between 17 and 72) may have been infected with SARS-CoV-2 since November 2021.
The study's most recent ( fifth) round, in which samples from 5,939 blood donors were analyzed, revealed that 56 percent of participants had antibodies to the SARS-CoV-2 virus in their blood, 5 percent more than two weeks prior. In February, the figure stood at 17 percent.
`` This is approximately the same result as in the previous round of the study, which shows that the COVID-19 pandemic is on the decline and that the decrease in the number of detected cases is not only due to fewer tests being performed, '' the press release said.
According to the SSI's updated statistics, Denmark has logged 3,061,773 confirmed COVID-19 cases and 5,723 deaths since the start of the pandemic.
To date, 80.8 percent of the country's population, or 4,754,182 people, have received two vaccine doses and 61.5 percent, or 3,616,885, a booster shot. | general |
New study shows COVID-19 can cause brain inflammation and small bleeds | A new study published in Nature Communications has offered the most comprehensive investigation to date into the effects of COVID-19 on the brain using nonhuman primates. The study found SARS-CoV-2 infection, regardless of disease severity, can lead to neuroinflammation and small bleeds which may account for many of the neurological symptoms reported by patients.
The study was led by Tracey Fischer from the Tulane National Primate Research Center. Recognizing the potential future need to develop nonhuman primate models for COVID-19 Fischer’ s research began early in pandemic.
The team’ s initial work revealed SARS-CoV-2 infections caused microhemorrhages in the brain. These preliminary findings came so early in the pandemic that experts not affiliated with the work were skeptical. At that point those neurological symptoms had not yet been detected in human patients.
“ You see the pathology, and it’ s so distinct and so profound, ” Fischer said. “ I’ ve been looking at the central nervous system for decades, so long that you know when something doesn’ t appear normal and appears to be in line with the infection. ”
Fischer and her team spent an additional year validating those initial findings, as other researchers began to find evidence of similar neurological symptoms in humans. Control animals were studied and research protocols were refined in order to affirm those initially detected brain changes were directly linked to the coronavirus infection.
Alongside the small bleeds, the researchers found severe widespread brain inflammation and neuron damage. Fischer said the neurological damage was not linked to the severity of respiratory disease. This means many animals displayed only mild COVID-19 symptoms yet still experienced neurological damage.
The new study also offers valuable insight into the ongoing debate over whether the neurological impact of COVID-19 is due to broader effects of systemic inflammation or the virus directly infecting the brain. Although the researchers did detect small traces of the SARS-CoV-2 virus in several parts of the brain, the majority of the damage was hypothesized as likely due to intermittent, localized hypoxia.
“ This was observed in all infected animals, regardless of disease severity, suggesting reduced brain oxygen may be a common complication of infection, ” the researchers concluded in the study. “ Even minor, but sustained, reductions in oxygen may promote injury, particularly among neurons, which appear to have suffered the greatest insult in this study. ”
The findings add to a growing body of evidence reporting on the effects of COVID-19 on the brain. These studies are helping shed light on a number of acute and chronic neurological symptoms associated with the disease, from fatigue and brain fog to mental health problems.
The researchers do note there are limitations to their findings, particularly in considering the animals used in the investigations were of an advanced age. So it is unclear whether older brains are more susceptible to this kind of cerebrovascular damage, and it’ s also still unclear whether this kind of neurological damage is reversible. Long-term follow-up studies on long COVID patients will be needed to answer these questions.
The new study was published in Nature Communications.
Source: Tulane University, NIH Office of Research Infrastructure Programs | science |
Airlines cancel hundreds of weekend flights as storms sweep through Florida | In this article
Airlines canceled hundreds of weekend flights and thousands more were delayed as thunderstorms in Florida slowed traffic in one of the country's top travel destinations during spring break.
More than 6,000 U.S. flights were delayed and 1,930 were canceled on Saturday, according to flight-tracking site FlightAware. Disruptions continue on Sunday with nearly 1,540 canceled and more than twice that number of delays, though Monday schedules appeared to stabilize.
Thunderstorms are especially challenging for airlines because they are harder to predict and plan for compared with other weather like winter storms and hurricanes, during which airlines often cancel flights hours if not days in advance.
Disruptions due to storms tend to cascade because crews and planes are left out of position for their assignments.
Southwest Airlines canceled 520 flights, or 14% of its Saturday schedule, and had 1,512 delays or 43% of scheduled flights, according to FlightAware. About 400 flights, 10% of Southwest's Sunday schedule, were canceled and another 25%, more than 900, were delayed.
Before the storms sparked delays in Florida, the airline had briefly paused departures early in the day to perform checks on a backend system that it had reset as part of regular maintenance overnight. Those systems are used for tasks including pre-departure paperwork.
Southwest said some of its crew members couldn't find hotel rooms amid the disruptions, something crews complained about last year.
`` With widespread cancellations in the midst of a busy travel season, hotel rooms were unavailable in a few cities, and late day Crew timeouts in those cities meant that some Crew Members were left without rooms, '' Southwest said in a note to crews on Sunday, which was seen by CNBC. `` We take that shortfall seriously and are working to follow up with affected crew members. ''
The airline waived fare differences for affected customers so they can rebook themselves online without waiting on the phone, a spokesman said. The airline started the day with about 400 cancellations because aircraft and crews were out of position after Saturday's weather, the spokesman added.
Air traffic controllers had slowed or paused inbound traffic altogether at several Florida airports Saturday, including Orlando International Airport, Miami International Airport and Tampa International Airport. Close to a third of Orlando departures were canceled and 42% were delayed.
`` Yesterday's weather in around Florida and resulting [ air traffic control ] initiatives impacted our operations with most northbound and southbound routes through and to Florida affected, American Airlines said in a statement. `` We're recovering from those disruptions today. ''
More than 65,000 American Airlines customers, including those on regional airlines, were impacted by the disruptions on Saturday, according to an internal tally, which was reviewed by CNBC. About a third of cancellations were tied to a lack of crew availability.
Dennis Tajer, spokesman for the Allied Pilots Association that represents American's pilots, said the airline needs to improve its technology to better allow pilots to pick up flights when there are disruptions.
Delta Air Lines said that the Florida weather also impacted its operation on Saturday. About a fifth of Delta and American's schedules were delayed, roughly 600 flights apiece. American had also canceled 363 flights, or 12%, while Delta had canceled 238, or 8%.
On Sunday, more than 500 American mainline flights were canceled or delayed, while Delta had 41 canceled flights and 366 delayed.
A third of Miramar, Fla.-based Spirit Airlines ' flights were canceled and a fifth were delayed. JetBlue Airways scrubbed a third of its schedule on Sunday, with another 31% delayed. New York-based JetBlue has a large presence in Florida as well as the Northeast.
Airlines are currently scrambling to staff up to handle the travel demand that surged as Covid cases declined this winter. Staffing shortages worsened flight disruptions last year.
Delta, American and Alaska Airlines pilots have picketed at airports in recent weeks as their unions push carriers ' management for better pay and more predictable schedules.
On Friday, Alaska Airlines canceled more than 100 flights and close to 80 more on Saturday. Some of its pilots had picketed at several West Coast airports Friday over a lack of progress in contract negotiations with the airline.
`` Alongside other carriers, we continue to be impacted by a national pilot shortage and the required training regimen to bring new pilots onboard, '' the airline said in a statement, which did not mention the pickets.
Airlines have increased flying to cater to customers returning after two difficult pandemic years but pilots and flight attendant unions have frequently complained about packed schedules and stresses on the road, such as a lack of hotel rooms or difficulty reaching company scheduling services.
`` The choke point has been in getting everyone trained as we 've ramped the airline back up and returned aircraft to service throughout the pandemic, '' Spirit Airlines CEO Ted Christie told an industry event Thursday. | business |
Tour of Flanders: What van der Poel, Pogačar, Uttrup Ludwig, Wiebes and more stars said at the start | Get access to more than 30 brands, premium video, exclusive content, events, mapping, and more.
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ANTWERP, Belgium ( VN): The biggest day of Belgian cycling arrived Sunday.
The men’ s and women’ s Tour of Flanders marks one of the high points of the spring with a race that every rider wants to win and every enthusiast wants to watch.
And to make it even better, spectators are back on the bergs after COVID restrictions saw the race go “ behind closed doors ” for recent seasons.
The men’ s Ronde rolled early doors in a cold and clear Antwerp Grotemarket, and VeloNews reporters Sadhbh O’ Shea and Andy Hood were there. The women’ s race got rumbling shortly after 1 pm in Oudenaarde and will return around one hour after the men.
Here’ s what some of the biggest names in the men’ s peloton said at the start Sunday morning.
Here we are now. # RVV22 pic.twitter.com/it9e4kr3Z1
Jumbo-Visma will have to approach the race differently to if Wout van Aert was here. There’ s still a lot of top competitors here – last year I went to the finish with Asgreen but without van Aret, so it’ s hard to say.
The second time on the Oude Kwaremont is usually the crucial part of the race because from there it starts to go really quickly, all the hills follow each other fast. Positioning is important, like all classics races.
My motivation is good after winning Dwars door Vlaanderen. This is a bigger goal than Wednesday, I worked hard to be ready and I hope to be at my top level.
This is super important for the team, like all the classics. We’ re well prepared, we did everything we could. We just have to enjoy it now.
No van Aert doesn’ t change the race for us, but it does change the dynamics of the race. We’ ll do many of the same things we were going to do anyway.
I hope the legs are as good as last year, The shape is there so I hope the legs are there as well. I’ m happy with where I am.
With the crowd, I think it will be crazy, I think it’ s going to be amazing. The last two years [ without crowds ] was a bit sad, but I think this year is going to be legendary.
It is my first time here and so far, so good. I hope it continues in the race. I have the sections written on my stem. I hope to know them by heart in a few years. Matteo [ Trentin ] will be my guide. He knows the roads here.
Roubaix is one of my biggest goals, but this is a monument as well so it’ s difficult to put all the money in one basket.
Tactics? It will be stupid of me to tell everyone what we’ re going to do.
You miss the crowds, they give you an extra push. Flanders with spectators, it’ s really amazing. So many people wait to see this race. All week, everything turns toward Flanders, many pages in the newspapers every day. Every five minutes you get a notification about Tour of Flanders.
There’ s a question mark with the team because nearly all of us have been sick recently. I think the shape of most of us isn’ t 100 percent. But sometimes you can make a good race without the best shape. We know that we improve race after race but if it will be enough, we don’ t know.
We have Asgreen who is one of the favorites, so we go for it. Mostly we’ re used to starting with four or five leavers and this year it’ s not the way. But we’ re going to fight for it.
Arriving here with the fans on the market square in Antwerp is one of the best moments of the year.
I’ m bruised but healthy [ after crashing at Dwars ]. That’ s better than the other way around. It’ s super sad for Wout that he’ s missing out. I wonder who will take control of the race. We’ ll ride in support of Greg Van Avermaet.
I’ m excited, I didn’ t realise that it was my 14th Flanders, that was pointed out to me yesterday. I’ m excited and the atmosphere with all the crowd here as well is already giving me good vibes. Part of the whole Flanders experience is having the crowds here and just really experiencing that Flanders vibe. It’ s going to be crazy.
I think it’ s really exciting that I’ m going to go up the Koppenberg. Everyone is just focused on this one point of the race. You’ re probably not going to win the race there but for sure if you’ re out of position or you have to unclip and walk then you’ re going to have to spend unnecessary energy there. It’ s going to be hard and everyone has the same instruction to be at the front at the bottom so it’ s going to be mental.
I think there will be a lot of spectators, especially on the Oude Kwaremont there are going to be people and I hope it gives me extra energy to go over the climbs. It gives me more motivation to go full gas. It’ s been a long time that there were people on the road, so it’ s nice.
I hope I can help my team as far as possible in the race. Floortje Mackaij is our final rider for it so I hope that I can help her as far as possible.
We’ ve got Coryn in really good shape so she is one of our options and we’ re just looking to see what goes on and see what SD Worx do.
I think the Koppenberg will change things completely. I think people are underestimating what it will do to the race. I think it will be in pieces after that and I think the race really starts from there. From there on, I’ m just closing my eyes until the finish.
Trek-Segafredo has had a good run of wins and they’ re ones to watch. Also, SD Worx you never know what they are going to do because they have so many winners in their team. And of course, Annemiek van Vleuten, she’ s always the thorn in everyone’ s side.
It’ s just so crazy here feeling the vibe again. It has been years since we have had a crowd. It gives me goosebumps. I love it so much, it’ s just so nice feeling it. It’ s going to be on the big climbs, and it will be crazy. I’ m just going to enjoy it.
I feel good, so let’ s just go out there and have some fun. It’ s nice to have lots of options and hopefully we can have lots of riders in the final so that we can play with multiple cards. There are a lot of strong riders here. Obviously, Balsamo has won almost all the WorldTour races, but SD Worx is interested in a hard race and Annemiek wants a hard race so there are multiple teams interested in a hard race, we’ re not alone.
Get the latest race news, results, commentary, and tech, delivered to your inbox. | general |
Oil markets pricing in demand loss or more output: Vitol | In this week's Market Movers Americas, presented by Jeff Mower: * US Gulf of Mexico offshore output...
The global oil markets are pricing in either a demand loss or more output from countries such as the US amid the global release of oil stocks and recessionary threats in some economies, the head of Vitol Asia said April 3.
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`` For the market to trade down as it has done, that's telling you that the market is expecting a demand loss... or a production increase from places like US shale of more than 2 million b/d, '' Mike Muller told the Gulf Intelligence daily energy markets podcast.
The US announced on March 31 plans to sell an unprecedented 1 million b/d from the Strategic Petroleum Reserve for the next six months as part of efforts to rein in gasoline prices that have soared following Russia's invasion of Ukraine.
The International Energy Agency followed suit and agreed on April 1 to a second emergency release of oil reserves in response to `` market turmoil ' caused by Russia's invasion of Ukraine, and said details of the release would come early next week.
The news of the global oil stocks release sent oil prices down, with Platts Dated Brent assessed on April 1 at $ 107.425/b, down 2.42% on the day, according to S & P Global Commodity Insights data.
The IEA had previously estimated that Russian oil losses could reach 3 million b/d in the second quarter, but most forecasts are more cautious estimating 1 million b/d - 2 million b/d.
S & P Global forecasts 2.8 million b/d of Russian crude production shut-ins due to export dislocations from sanctions and buyer aversion from late April through the end of 2022. Disruptions are estimated to moderate to 2 million b/d by end-2023 as barrels are redirected and/or more cargoes are `` cautiously purchased. ''
The crude markets are also dealing with lockdowns in China, the world's second largest oil consumer, which has imposed restrictions on movements in several cities to fight the spread of omicron variants.
Moreover, OPEC+ is likely to keep increasing oil production quotas according to previous plans, despite the disruption of Russian supplies, Muller said.
`` There was a global stock draw that the world is predicting on the basis of OPEC+ continuing to hold their line, not least because there is very little extra production available out of anywhere than core OPEC these days, '' he said.
OPEC+ ministers in their March 31 meeting stuck to their planned 432,000 b/d production hike in May, despite pressure to tap additional spare capacity and boost output further.
The OPEC+ alliance, which controls some half of global oil supply, has gradually rolled back the record production cuts it instituted during the worst of the pandemic, saying it aims to balance supply with emerging demand from the recovery.
Internal OPEC+ analysis showed that the group pumped 1.053 million b/d below its targets for February, as many members were unable to raise production due to natural field declines, inadequate infrastructure and a general lack of investment exacerbated by the coronavirus market crash.
The delay in reaching an Iranian nuclear deal is also another setback for oil markets, which were anticipating a return of their crude in the second quarter of 2022, Muller said.
`` Everyone was expecting the return of Iranian supplies, '' he said. `` I think nobody believes that is going to happen in Q2 and it looks less likely than it was a few weeks back for various reasons. ''
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Japan looks to accelerate vaccine research and development with new government body | Japan aims to accelerate its vaccine research and development under a new government body after lagging behind other advanced countries in developing vaccines during the early stages of the coronavirus pandemic.
The Strategic Center of Biomedical Advanced Vaccine Research and Development for Preparedness and Response ( SCARDA) was established in late March within the Japan Agency for Medical Research and Development to promptly deliver safe and effective vaccines against infectious diseases on the government’ s priority list.
The government also aims to contribute to the international community by making the vaccines produced in Japan available abroad.
The organization, SCARDA, will provide stable long-term support for research by institutions and companies, while also providing funding speedily and flexibly during public health emergencies.
“ We will accumulate data and evidence in normal times and make the most of them in a health emergency, ” a SCARDA official said.
SCARDA is expected to play a similar role to the U.S. Biomedical Advanced Research and Development Authority and the National Institutes of Health in the development of COVID-19 vaccines, according to the official.
SCARDA shares with the U.S. institutions a commitment to collaborating in public-private partnerships and early investments and engagement, the official said.
“ Our primary focus is especially how we can shorten the time and make vaccines available quickly after a breakout in line with the ‘ 100 Days Mission’ of the G7 ( Group of Seven), ” the official said, without elaborating on a set time frame.
The Group of Seven industrialized nations, including Japan, has set an ambitious target of having safe and effective diagnostics, therapeutics, and vaccines ready to deploy within the first 100 days of a future pandemic threat being identified by harnessing scientific innovation through public-private collaboration.
The Group of 20 economies also supports the mission, with their leaders agreeing to shorten the cycle for developing diagnostics, therapeutics, and vaccines from 300 days to 100 days following the identification of future pandemic threats.
However, the development of vaccines against infectious diseases is considered a high-risk project for a company because it is almost impossible to predict when and in what magnitude a virus will emerge.
Most vaccine candidates do not make it to market, and the costs of failed products must also be absorbed, the U.S. Department of Health and Human Services says.
As part of efforts to hedge capital investment risks, production facilities of vaccines for contingencies will serve as production facilities of other biological drug products during regular times, according to the Japanese government’ s plan.
With the establishment of SCARDA, the government will directly support private vaccine development by covering research and development costs. At the same time, the official said it has not ruled out the possibility of committing in advance to purchase a successful vaccine.
The government plans to spend ¥51.5 billion ( $ 420 million) to prepare major development sites and allocate ¥150.4 billion for research and development of vaccines against communicable diseases found on its priority list, along with new technologies associated with them. | tech |
What’ s the Skinny on Those Pandemic Pounds? New Insight on Weight Gain During the COVID-19 Quarantine | New study in the American Journal of Preventive Medicine sheds light on weight gain during the COVID-19 quarantine.
More Americans weighed in as obese during the first year of the COVID-19 pandemic than in the previous year. A new study in the American Journal of Preventive Medicine, published by Elsevier, presents evidence from a large, nationally representative survey that documents this trend and helps to explain behavior changes that led to widespread weight gain in 2020.
“ Previous studies present evidence that intra-pandemic changes in risky dietary and other health-related behaviors likely contributed to the rapid rise in body weight during this period. Adults who reported weight gain also reported more frequent snacking and alcohol intake; increased eating in response to sight, smell, and stress; and decreased physical activity, ” explained lead investigator, Brandon J. Restrepo, PhD, US Department of Agriculture, Economic Research Service, Food Economics Division – Diet, Safety and Health Economics Branch, Washington, DC, USA.
Adult obesity in the US was elevated and trending upward prior to the COVID-19 pandemic. While several studies have reported on small and relatively homogenous online surveys that track weight gain in the US adult population during the initial pandemic period, this study is the first to use data from the Behavioral Risk Factor Surveillance System ( BRFSS), a larger, nationally representative survey of the US adult population. It contains data on health outcomes, health-related risk behaviors, preventive services, and chronic medical conditions.
Percentage changes in obesity and obesity-related risk factors during the COVID-19 pandemic relative to the 2019 to pre-pandemic 2020 period. Source: Author’ s calculations using data from the 20112020 Behavioral Risk Factors Surveillance System. Credit: Brandon J. Restrepo, PhD
To estimate the overall changes in adult obesity prevalence and four obesity-related risk factors during the COVID-19 pandemic, the analysis of the BRFSS data employed linear regression models that control for age, sex, race/ethnicity, education, household income, marital status, number of children, survey year indicators, and state of residence indicators.
According to the analysis of more than 3.5 million US adults ( aged 20 and older) from the 2011–2020 BRFSS, obesity was 3% more prevalent during the year beginning March 2020, compared with the 2019 to pre-pandemic 2020 period. The study also found statistically significant changes among US adults in four obesity-related risk factors during the COVID-19 pandemic: exercise participation, sleep duration, alcohol consumption, and cigarette smoking.
While exercise participation and sleep duration were higher by 4.4% and 1.5%, respectively, the number of days in which alcohol was consumed was 2.7% higher and cigarette smoking prevalence was lower by 4%. The overall increases in exercise and sleep were not sufficient to offset the impact of other behaviors, resulting in an average 0.6% rise in body mass index during the COVID-19 pandemic. Although smoking cessation is a healthy step, it is known to cause some weight gain.
“ Our results, which are broadly consistent with what prior studies have found using smaller and less representative samples, contribute additional insights that can serve to inform policymakers about the state of the US adult obesity epidemic and obesity-related risk factors, ” noted Dr. Restrepo, adding, “ Because obesity affects some adults more than others, it would be helpful to further explore the changes in the rates of adult obesity by demographic subgroup and socioeconomic status. ”
Reference: “ Obesity Prevalence Among U.S. Adults During the COVID-19 Pandemic ” 4 April 2022, American Journal of Preventive Medicine. DOI: 10.1016/j.amepre.2022.01.012 | tech |
‘ My stepmother is crying poor, and selling everything of value. She's cut off all communication’: My father died without a will and I am his only child. What now? | Dear Quentin,
My father recently passed away. He was married to my stepmother for 33 years. Prior to his death, he wanted to buy me a manufactured home, and told me to look for a home costing up to $ 200,000. I couldn’ t find one in an area that suited me before he passed.
Unfortunately, he did not leave a will. My stepmother is crying poor, and selling everything of value. She has cut off all communication from me and I found out that she was able to get over $ 70,000 that he had in a savings account. Shouldn’ t that be part of probate?
Also, I found out that when my father bought his house he and my stepmother were only “ tenants in common ” and she only had a 13% interest in the house. I am my father’ s only child. What happens with his estate? How are his assets supposed to be divided?
We live in California.
Concerned Daughter
Dear Concerned,
Given that your father died without a will, his estate should go through probate and the court would provide an administrator to take an accounting of his assets, and distribute them among his legal beneficiaries, per the intestacy law in California.
As for that $ 70,000: If the account in question was a joint savings account with the right of survivorship or a payable-upon-death account, your stepmother would inherit that account, and it would not go need to go through probate.
That said, she should not sell any property that could or should go through probate, but unfortunately a “ land grab ” is
not — alas — an unusual response
, especially if there is a partner or child remaining in the family home.
Your father’ s share in their home is part of his estate, and subject to probate. The value of the home is considered on a “ step-up in basis, ” meaning that it’ s valued at the current market price rather than the price he purchased the home.
“ Tenants in common ” — where each party owns a specific share and does not automatically inherit their spouse’ s share — is an unusual way for a married couple to own a property in California,
but it is as an option
.
“
‘ Tenants in common creates a problem for the remaining spouse when there is a second heir, and no will.’
”
It also creates a problem for the remaining spouse when there is a second heir and no will. Under
California intestacy law,
your stepmother would inherit all community property, and 50% of his separate property, with the rest going to you.
Other considerations: California is a community-property, rather than an equitable-distribution, state. Under those rules, significant assets acquired during the marriage are viewed as marital or community — rather than separate — property.
“ Simply because two people are married does not necessarily mean that they own property as community property, ”
according to Schorr Law.
“ Generally speaking, if property is acquired during the marriage, it is presumed to be community property. ”
“ However, there are exceptions. For example, if the deed or another agreement specifies otherwise. To the extent real property is held as basic community property, there is no automatic right of survivorship, ” it adds.
If they had purchased the property as “ joint tenants with rights of survivorship, ” the most common ownership agreement among married couples in California, they would each own 50% and would inherit the property upon the other’ s death.
It’ s surprising that your father would take such care over the deed of his home, yet not leave a will, and it’ s equally unfortunate that he would offer you a $ 200,000 home but not make provisions for that before he died.
It’ s a missed opportunity, and a hard lesson to learn.
Yo
u
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‘ We’ ve been left out in the cold’: My mother named my sister beneficiary of her estate, but wrote a letter wishing to divide it among her 3 children. What now?
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‘ We’ re concerned this woman may persuade him to leave his house to her’: My father, 85, moved in with a female friend. How do we stop her taking his money?
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‘ She had a will, but it was null and void’: My friend and her sister are fighting over their mother’ s life-insurance policy and bank account. Who should win out? | business |
The Ukraine war has undermined the advice of the new IPCC report — Quartz | The global economy must pursue “ a substantial reduction in overall fossil fuel use ” to have any hope of avoiding catastrophic climate change, a major new UN report says. But as governments look for alternatives to oil and gas from Russia, the opposite will happen: investment in drilling is only going to increase.
The third report from the Intergovernmental Panel on Climate Change ( IPCC), released on April 4 after the longest negotiating session in the group’ s three-decade history, focuses on the steps needed to limit global warming to 1.5 degrees Celsius above pre-industrial levels, the goal enshrined in the Paris Agreement. Previous sections of the report covered basic climate science and steps for adaptation.
The world is up 1.1 degrees already, and on track to hit 2.7 degrees by 2100. And we have already used up four-fifths of the “ carbon budget ” that would need to be followed to have even a 50-50 chance of hitting 1.5, the IPCC report says.
In that context, UN secretary-general António Guterres said in a press conference, “ the truly dangerous radicals are the countries that are increasing the production of fossil fuels. ” But today, that group includes the US, Europe, and most other major economies.
In a May 2021 report, the International Energy Agency made clear that the only way to hit 1.5 was to immediately cease any expansion of fossil fuel production and invest only enough to keep some existing wells pumping.
But as the economy recovers from covid and Russia becomes persona not grata, most oil and gas companies have big expansion plans. In an April 4 letter to shareholders, JPMorgan Chase CEO Jamie Dimon—whose bank is the world’ s top fossil financier—called for the “ immediate approval for additional oil leases and gas pipelines. ”
In a perfectly balanced energy market, Europe and the US might invest just enough to precisely offset Russian oil and gas which, without buyers, could be left in the ground. That would avoid breaking the carbon budget any more than it already is. But the budget is already overshot if you count emissions from fossil fuel projects that are currently under development, the IPCC report says. Anything more would bury that goal completely.
The good news, the IPCC says, is that the costs of clean energy have fallen so much that low-cost ( less than $ 100 per ton of CO2) replacements for fossil fuels could cut global emissions in half by 2030.
Still, especially if new fossil infrastructure is forthcoming, a significant scale-up of technologies to capture emissions, both from specific sources like power plants and from the general atmosphere, is “ unavoidable, ” the report says. This is the first IPCC report to make an unequivocal case for carbon removal. That will include nature-based solutions like reforestation, and high-tech carbon-sucking machines.
Still, said Stephanie Roe, lead climate scientist at the World Wildlife Fund and an IPCC author, “ cleaning up emissions after the fact is much more difficult and costly than it is to prevent them in the first place. ” So the most urgent priority is to hit peak global emissions as soon as possible, and start to bend the curve down. Right now, they’ re higher than ever. | tech |
Medicare now covering cost of at-home Covid tests for beneficiaries | Medicare beneficiaries can now get at-home Covid tests at no cost, the government announced Monday.
People with Medicare Part B ( outpatient care coverage) — including Advantage Plan enrollees — will be able to get up to eight over-the-counter tests per month for free from participating pharmacies and health-care providers, according to the Centers for Medicare and Medicaid Services.
The initiative comes after Medicare was not included in a January mandate from the Biden administration that private insurers must cover the cost of at-home tests ( also up to eight per month). This marks the first time Medicare has covered an over-the-counter, self-administered test at no cost to beneficiaries.
More from Personal Finance:1 in 5 workers runs out of money before payday, survey findsPooling money makes couples more likely to stay togetherThere's still time for 2021 IRA contributions. What to know
About 63.3 million people are enrolled in Medicare. Most of the beneficiaries, 55.1 million, are age 65 or older, and the balance are generally younger with permanent disabilities. These populations are among the groups at higher risk for severe illness from Covid.
A list of eligible pharmacies and other health-care providers that are participating in this initiative can be found on the CMS website. However, it's worth checking with your pharmacy or doctor to find out if they are participating if you don't see them on the list.
Medicare beneficiaries also can still access free testing outside their home at one of more than 20,000 testing sites where lab-based PCR tests, rapid PCR tests and rapid antigen tests are available.
You also can order two sets of four tests for free through Covid.gov. The government website, which is available to all households, requires you to provide only your name and address; no insurance information is needed. | business |
Omicron sub-variant BA.2 makes up 72% of COVID variants in U.S. - CDC | The U.S. national public health agency said on Monday the BA.2 sub-variant of Omicron was estimated to account for nearly three of every four coronavirus variants in the country.
Overall COVID-19 cases in the United States have dropped sharply after hitting record levels in January, but a resurgence in cases in parts of Asia and Europe has raised concerns that another wave could follow in the United States. The country's health experts, however, believe it is unlikely.
The seven-day moving average of U.S. COVID cases was 26,106 as of April 1, marginally lower than 26,309 from a week earlier, as per data from the U.S. Centers for Disease Control and Prevention ( CDC).
The highly transmissible BA.2 sub-variant makes up 72.2% of the COVID variants in the United States, as of April 2, up from nearly 57.3% in the preceding week, according to CDC estimates.
BA.2 now makes up about 86% of all sequenced cases globally, according to the World Health Organization. It is known to be more transmissible than the BA.1 and BA.1.1 Omicron sub-variants, however, the evidence so far suggests that it is no more likely to cause severe disease.
Amid waning immunity and risks posed by the Omicron variants, U.S. health regulators authorized a second booster dose of Pfizer/BioNtech and Moderna's vaccine last week, for people aged 50 and above, as well as for younger people with compromised immune systems. ( Reporting by Bhanvi Satija, Leroy Leo and Manas Mishra in Bengaluru; Editing by Vinay Dwivedi) | business |
Critics push IMO’ s Lim to get up to speed on decarbonisation | The IMO must get up to speed in formulating and implementing concrete and demanding measures to decarbonisation, said industry and government critics
IMO secretary general Kitack Lim faced both diplomatic opposition and direct challenges from top industry and government speakers at an opening-day session of this year’ s long-delayed Nor-Shipping industry congress.
Lim delivered a plea for greater collaboration and communication among its member states and among industry stakeholders to meet the urgent goal of decarbonisation.
The IMO is currently revising its 2018 decarbonisation strategy with a mid-2023 deadline.
But it is the IMO itself that runs the risk of being the party responsible for a failure to decarbonise shipping, Trafigura global head of fuel decarbonisation Rasmus Bach Nielsen told delegates.
“ Collaboration will not solve the problem, ” said Bach Nielsen. “ The problem is the price gap [ between present and future fuels ]. ”
Only government action driven by international regulation and financial support can bridge that gap. The IMO is responsible for creating a global framework to address the cost of future fuels, and if it fails to do so, it will be responsible for the consequences, said Bach Nielsen.
Trafigura has long touted what it calls a “ feebate ” system — a high carbon levy on the use of fuels with CO2 intensity above a benchmark level, with the proceeds used to fund a subsidy for purchase of fuels below that level.
Bach Nielsen has previously criticised the EU for using parts of the proceeds of its emissions trading system for unrelated purposes such as Covid relief support.
Shipowner Synnove Seglem expressed agreement with her fellow panellist that carbon levies need to feed directly back into technical development. Seglem is deputy managing director at Knutsen OAS Shipping and vice president of the Norwegian Shipowners’ Association.
Magda Kopczynska, director for waterborne transport at the European Commission ( EC), put her challenge to the IMO more diplomatically than Bach Nielsen.
“ We want to make sure the revised IMO strategy will be fit for the future, ” she said.
She emphasised the role of the EC in implementing its own regional goals as a way of pushing the IMO to implement stronger global ones.
“ It is good to talk after the IMO because we agree on so many things. But I want to use this opportunity to challenge all of us a little bit, ” said Kopczynska.
Details of an emissions trading system for the EU are to be formalised this year and implemented in 2023.
“ What better way is there to see how a carbon pricing [ scheme ] could work than to have one in action? ” she asked delegates rhetorically.
Follow all of TradeWinds coverage from Nor-Shipping here. | general |
Find Autonomous Technology and Everything In Between at DesignCon | Find Autonomous Technology and Everything In Between at DesignCon | designnews.com
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A talk with keynoter, Dr. Jose Morey, consultant for NASA, Forbes, MIT, and the White House Office of Science and Technology Policy.
Technology is used in more ways than we can imagine. While many consumers think of everyday products such as their cell phones and the Wi-Fi router, advanced technology is the nucleus of modern-day life, from the electronics that drive a Tesla, to space exploration, to profound disease discovery and advancing patient care. Technology is evolving and changing society for the better.
The latest tech innovations paved the way for the medical field to advance the healthcare industry and combat the COVID-19 pandemic. The use of AI and ML is propelling this movement, with the market for surgical robots set to reach $ 13 billion by 2025. With the advancement of healthcare delivery alongside self-driving cars and space tech, everyday life is becoming more autonomous than ever.
It is hard to imagine a world without all the technological advancements that have taken place over the last 50 years, but what comes next? Spearheading this conversation is Dr. Jose Morey, prominent keynote speaker at
, the nation's largest event for chip, board, and systems design engineers happening April 5-7, 2022, at the Santa Clara Convention Center. I had the pleasure of speaking with Dr. Morey about what attendees can look forward to learning during his upcoming keynote presentation entitled ``
, '' which will take place on April 7 from 10:00 -11:00 a.m.
Suzanne Deffree: You have quite a diverse and impressive background. Could you tell us about your experience as a consultant for NASA,
It's always been interesting to work with organizations at the cutting-edge of emergent technology, such as NASA and Forbes. It's remarkable to meet new companies and industries doing the same thing and pushing the envelope. It was an honor to work specifically for the White House Office of Science and Technology Policy around the COVID-19 project, an initiative set up by the OSTP to utilize artificial intelligence to combat the pandemic by expediting therapeutic and diagnostic discovery using machine learning and natural language processing. The incredible thing about that project is that there was a documentary filmed by relativity studios called “ On the Merit: Pandemic, ” which also went on to be utilized by the
and now is being implemented with drug discovery and other disease discoveries.
Suzanne Deffree: You have been referred to as the `` World's First Intergalactic Doctor. '' What currently excites you about the future of space tech?
The concept that we will soon have a global economy in space. The wealth generation and the opportunities that potentially will be created for the world are simply amazing. It will be the first, truly limitless, economy and industry. There's no limit to how much wealth it could potentially generate, which will hopefully help the inequalities that have been there beforehand. The concept that people will soon be working in space, not just government employees but private employees and private industries, potentially towards the end of our lifetime or maybe well of my lifetime, we 'll have people living and playing and procreating in space. And the concept that there will be life on moons and other planets makes modern society an amazing time to be alive and be a human to see this kind of evolution in our species.
The emerging technology that's being developed, we often think, is almost science fiction but is actually science fact. It's everything from advanced robotics to cryogenics to quantum computing and biomechatronics. The utilization that we're doing with bioengineering and synthetic biology to be able to manipulate our surroundings is impressive. The advancements in material science, additive manufacturing, automation, robotics, and the combination of artificial intelligence, particularly healthcare and autonomous surgical units, are mind-boggling. The innovations that we used to see in Hollywood or read about in books are now actually a part of our everyday applications and things that we couldn't even dream of before. We're actually accomplishing it now or trying to do it in the very near future.
The concepts that we have around advanced propulsion systems, artificial gravity generation, and new types of mobility are helping utilize the warping of spacetime as a means of travel and other potential utilities that we can produce or manipulate. It's just amazing the things that are coming out, and I 'm excited for everyone at DesignCon to see all the incredible applications that are out there.
Being able to interact with all the amazing people at DesignCon. It's been a long time since these events have occurred, and DesignCon is a keystone event within the industry. This is an unmissable conference in which I 'm excited to partake with all the people there. I think one of the unique things about going to these types of conferences where you can meet people at the top of their games and industries from different walks of life, where very unique innovations and partnerships can grow out of these types of conferences that can't happen organically through the virtual world. At least not yet.
You won't want to miss Dr. Jose Morey's keynote address and the chance to mingle with the industry's leading visionaries at this year's DesignCon exhibition and conference.
today to join your peers for three days of technical and forward-looking education created for engineers by engineers, networking, deal-making, and new technology discovery.
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Supply-Chain Issues Not Affecting Semi Supplier Revenues | Supply-Chain Issues Not Affecting Semi Supplier Revenues | designnews.com
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Semiconductor industry revenue reached a record $ 586.8 billion in 2021, according to market research firm Omdia.
Led by Samsung and Intel, semi revenue topped half a trillion dollars in 2021.
Supply-chain issues brought about by the COVID-19 pandemic have not adversely affected semiconductor industry revenue, according to a study by market research firm Omdia. In fact, semiconductor industry revenue topped half a trillion dollars in revenue, evidence that the demand for chips remains strong as product and technology development continues.
Omdia noted that Samsung has maintained its position atop the semiconductor industry in Q4 2021, when it generated $ 19.85 billion in revenue, edging out Intel which generated $ 19.976 billion. But overall, Intel topped the revenue charts in 2021, generating $ 76.6 billion, comprising 13% of all semiconductor revenue for the year.
According to Omdia, Intel’ s 2021 revenue growth was nearly flat from 2020, which contrasted with the following top nine semiconductor firms, which all experienced year-over-year ( YoY) revenue growth above 15%.
According to Omdia, microprocessor units, Intel’ s main revenue source, grew at an overall rate of 11% year-over-year in 2021, which trailed the overall semiconductor growth level of 24%.
Samsung, which was second to Intel with sales of $ 75.2B, finished the year strong thanks to strong sales of DRAM and NAND components. Those sectors were up 42% and 23% in 2021, according to Omdia. Samsung is the industry’ s leading supplier of both DRAMs and NANDs.
According to Omdia, total 2021 semiconductor industry revenue of $ 586.8 billion was $ 100 billion more than the next highest year on record, 2018, when the industry brought in $ 484.7 billion. Year-over-year revenue growth in 2021 was 24.2%, the second-highest on record since Omdia began tracking the metric in 2002.
`` Year-over-year growth in 2021 is significant because the prior year was not a recovery year, but an above-average year with 10.4% growth, '' Leimbach said, adding that the long-term year-over-year growth for the semiconductor market is 6.8%. '' ( See illustration.)
Of the 247 companies surveyed by Omdia, 145 ( 59%) had annual semiconductor revenue growth greater than 20% in 2021. The strong 2021 was not specific to a few of the largest semiconductor firms but spread through the majority of players in the industry.
`` Demand continues to be strong in the work-from-home era brought about by the global pandemic and supply tight for many components, '' said Craig Stice, Chief Semiconductor Industry Analyst at Omdia. `` Supply shortages throughout the semiconductor landscape resulted in rising ASPs, which helped lift revenue. The resulting strong annual revenue was significantly above the historical average, 24.2% versus 6.8%. ''
2021 may not be easy to top. Whether the industry can maintain its robust 2021 growth levels is open to debate. Shortages of semiconductors and other electronic components have so far shown no sign of easing so far, and no relief is expected for at least another year. But 2022 has started in a fairly promising manner, as the SIA ( Semiconductor Industry Association)
semiconductor industry sales were $ 50.7 billion in the month of January 2022, up 26.8% over the January 2021 total of $ 40.0 billion, though 0.2% less than the December 2021 total of $ 50.9 billion.
The SIA in February projected global semiconductor industry sales to grow 8.8% over 2021, as suppliers bring more capacity online to meet pent-up demand.
in Licking County, Ohio, investing $ 20 billion. The project spans nearly 1,000 acres and is the largest private sector investment in Ohio industry.
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China’ s Covid Strategy Jars With Food Security Goal in Northeast | The information you requested is not available at this time, please check back again soon.
A resident picks up a bag of vegetables delivered by the government during a citywide lockdown in Shanghai on April 3. Photographer: Qilai Shen/Bloomberg, Bloomberg
( Bloomberg) -- The conflict between China’ s Covid-Zero policy and pursuit of food security has come to the fore in Jilin province, with lockdowns disrupting crucial farm work in the country’ s second-biggest corn growing region.
The northeastern province has been sealed off for weeks amid a surge in infections. That’ s preventing farmers from going out into the fields to plant crops this spring, adding to the challenges the country faces in securing food supplies at a time when the war in Ukraine has sent prices soaring.
Less clear is how long the disruptions will last and whether this will affect output. China is the biggest corn and soybean importer and has bought record quantities in recent years due to a domestic shortage, contributing to a surge in global prices. As the war in one of the world’ s major breadbaskets rages on, Chinese buyers have turned to U.S. grains to replace supply from Ukraine.
Officials in Jilin are aware of the risks, stressing in recent days that epidemic control and spring planting are both key priorities. Authorities are to ensure that farmers can return to their hometowns to work and that supplies of seeds and fertilizers can reach the fields in time, according to local media reports.
“ Farming waits for no one, ” Jilin authorities said in a WeChat statement late Monday. Farmers can apply to return home from April 5 if they fulfill certain conditions, including having a negative test and not being a close contact.
Hours after delivering the biggest interest-rate hike in 22 years in Canada, Tiff Macklem had a message for investors: There’ s no reason to worry about inflation getting out of hand.
Canada's big banks didn’ t waste much time following the Bank of Canada’ s lead, announcing Wednesday afternoon they will raise their prime rates half a percentage point to 3.2%, effective Thursday.
The Bank of Canada raised its interest rate by half a percentage point in its biggest hike in 22 years and said rates are poised to move significantly higher as it moves aggressively to wrestle inflation down from a three-decade high.
It’ s decision time for the people who control the fate of one of Canada’ s biggest-ever mergers. | general |
Stocks making the biggest moves midday: Twitter, Starbucks, Tesla and more | In this article
Check out the companies making headlines in midday trading.
Twitter — The social media company soared 27.1% after a filing revealed that Elon Musk has taken a 9.2% passive stake in the firm worth about $ 2.9 billion. The purchase came weeks after the Tesla CEO polled his 80-plus million Twitter followers about whether the platform adheres to free speech principles. Musk also recently hinted at starting his own site. The move is sparking speculation among analysts that Musk could take a more active ownership in Twitter or even consider a takeover down the road.
Tesla — Shares added 5.6% after Tesla reported first-quarter electric vehicle deliveries. The more than 310,000 vehicle deliveries marked a quarterly record, but slightly missed consensus Wall Street estimates. Most analysts attributed the miss to Covid shutdowns in Shanghai, where Tesla has a major factory.
Starbucks — The coffee chain fell 3.7% following the suspension of its share repurchase program. The decision comes as Howard Schultz returns to the helm as CEO of the company and amid a greater union push from the firm's baristas.
JD.com, Netease, Alibaba, Tencent Music – U.S.-listed shares of Chinese companies rallied after China proposed revising confidentiality rules regarding audit oversight. The move could prevent those companies from being delisted in the U.S. JD.com jumped 7.1%, Netease rose 2.4%, Alibaba gained 6.6% and Tencent Music added 10.7%.
Hertz — Shares of the rental car company surged 10.7% after Hertz announced a partnership with electric vehicle company Polestar. As part of the deal, Hertz will purchase up to 65,000 electric vehicles over the next five years, according to a news release.
Logitech — The stock rose 7% after Goldman Sachs upgraded the company to a `` buy '' from `` neutral '' and said it could see big gains from growing trends toward gaming and videoconferencing.
Quest Diagnostics – Shares slipped 1.3% after Citi downgraded the diagnostic information services company to neutral from buy, due to uncertainty around its post-pandemic model. Citi cited Quest's margin outlook this and next year as well as heightened labor pressures and volume declines.
Baxter — Shares fell 4% after Goldman Sachs downgraded the stock to a sell rating from neutral. The firm said the call is due to Baxter's `` over-indexing to headwind variables and numbers being at risk. ''
Ollie's Bargain Outlet Holdings — The retail stock jumped 15.7% after Wells Fargo upgraded Ollie's to overweight from equal weight. Wells Fargo said that the stock could prove to be a `` coiled spring '' after the company has worked through its pandemic-era disruptions.
— CNBC's Yun Li, Samantha Subin, Sarah Min, Jesse Pound and Tanaya Macheel contributed reporting. | business |
New omicron subtypes found in China and the UK — Quartz | On Monday ( April 4), China’ s Center for Disease Control and Prevention announced that it had sequenced a new subvariant of the omicron variant, according to the state-run Global Times.
The subvariant, labeled BA.1.1., does not match other coronavirus types sequenced in China or reported to the global variant database, and was found in a mild covid case in Suzhou, a city next to Shanghai.
China is experiencing its largest wave of covid infections since the start of the pandemic, with Shanghai, a city of 25 million, currently under a citywide lockdown. On Sunday, China reported more than 13,000 new cases. Local authorities have said omicron subvariant BA.2 is behind the new outbreaks.
The UK has likewise identified a new subvariant of omicron it has called XE. According to the UK Health Security Agency ( UKHSA), hundreds of people in the UK have so far been found to be infected with XE, a small fraction of total covid infections in the country. It is too early to tell if XE is more transmissible than other subvariants of omicron, though it has been detected beyond the UK, in Thailand.
The announcements of new omicron subvariants highlight the ongoing potential that another dangerous covid variant may yet emerge. However, as much of the world unwinds its pandemic restrictions, some covid gene sequencing and monitoring systems are being dismantled along with them.
Even as the UK’ s world-leading covid surveillance system turned out new information about omicron’ s subvariants, the government pushed ahead on Friday ( April 1) to shut down two virus surveys and scaled down a third, according to The New York Times.
Testing has dropped dramatically in Israel, which earlier had gathered important information on the effectiveness of vaccines against variants that informed governments around the world. Denmark, which had an ambitious gene sequencing program at the height of the pandemic, stopped requiring testing for most people, shifting instead to monitoring wastewater as an indicator for spikes of covid cases.
The drop in global covid data may make it more difficult to predict surges and understand new variants, and restarting surveillance programs may prove difficult should a new variant require it.
South Africa, which was the first to name the highly transmissible omicron variant, and the US, are continuing their gene sequencing programs, as is China, which is pursuing a covid-zero policy at odds with global trends. According to the Global Times, Suzhou city, where the new subtype was discovered, conducts gene sequencing for each new covid case. | tech |
A Flood Of Change: Leading Through Times Of Overload |
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How to systematically build your organization’ s capacity for change.
By David Michels
This article originally appeared on Forbes.com.
A recent headline in the New York Times seemed to say it all: “ There Are Almost Too Many Things to Worry About. ” Then, a few days later, on the second anniversary of the World Health Organization’ s Covid-19 pandemic declaration, the American Psychological Association published a set of “ alarming ” findings about how overwhelmed Americans feel. According to its Stress in America survey, on top of the enduring stress of Covid-19 and its tragic death toll, 80% or more of respondents also find inflation, supply chain issues, global uncertainty, and the war in Ukraine to be sources of significant stress.
Globally, we are in a moment of overload. Extraordinary forces are affecting our economy, our communities, and our workforce, sometimes feeling like an overwhelming flood. The task of leading any organization in today’ s rapidly changing environment is indeed a complicated responsibility.
One place to look for guidance is how companies embark on transformative change. People have a limited capacity to absorb change, and each of us has a different level of resilience. As a result, efforts to meaningfully transform businesses can easily overwhelm employees and organizations.
Capacity is one of nine factors that determine an organization’ s power to change, according to the latest Bain & Company research. Organizations can expand their capacity for change by taking five foundational steps:
Effective managers rigorously set priorities, limiting change to what can be accomplished without overload. One way to do that is a one-in/one-out policy: For every new initiative added to the agenda, another needs to come off. Walter Isaacson, author of the seminal biography Steve Jobs, recounts how the Apple founder approached this. He told his management team to reduce their list of priorities to the top 10; then he crossed off numbers 4 through 10, declaring “ We can only do three. ” While this may sound extreme, it can be an effective way to clear out clutter and focus on the initiatives that truly offer the greatest payoff.
Ultimately, the goal of any leader should not be just to manage within certain constraints, but to actually increase the organization’ s overall capacity to change. To do this, it is important to be able to predict where in an organization initiative overload might occur and then channel resources to those places to help absorb stress and build change muscle. This can include activities such as:
Consider the approach the executive team of a global consumer products organization took as part of its transformation. First, the team grouped employees by their importance to creating change and by the degree to which they would be affected by the change. Those results were mapped on a two-by-two grid. In the upper right-hand quadrant were the employees most likely to be overwhelmed: Their help was critical, and they faced a high degree of change. The executives next overlaid all their transformation initiatives on the individuals in the organization who would actually have to perform the work. This clearly identified the places—and people—that would come under the greatest pressure and need the most help.
The organization used this information to focus its efforts and increase its ability to absorb change. Executives added resources in the areas of potential overload and altered the sequence of initiatives to create a more realistic critical path. They helped their business units and line functions by filling key roles with more resilient talent, providing focused training, and reinforcing Agile behaviors—including using discrete time-boxed sprints, product backlogs, and regular huddles.
Nothing will make our current moment an easy one, but it is possible for leaders to pivot from a flood management challenge to a change capacity opportunity by systematically building resilience and agility into their organizations.
Worley’ s Francis McNiff joins Bain's Dave Michels to discuss the organization's change journey.
With survival and growth riding on a company’ s ability to hire the best talent, more executives are finding creative ways to solve the people equation.
Today’ s challenges are forcing leaders to rethink their approach to change management.
It’ s a bit of a cliché, but it’ s still true that most change efforts fail.
Bain's David Michels appeared on BBC World News to discuss the volatility of industries amid pandemic-induced restrictions, and how companies can improve their ability to adapt.
Stay ahead in a rapidly changing world. Subscribe to Bain Insights, our monthly look at the critical issues facing global businesses.
© 1996-2022 Bain & Company, Inc. | business |
Social Security offices reopen this week. How to reduce your wait time | Social Security beneficiaries soon will have one more way to seek assistance from the government agency as local offices are slated to reopen this week.
Starting Thursday, April 7, the Social Security Administration will restore in-person services, including for people who do not have appointments, acting Social Security Commissioner Kilolo Kijakazi announced Monday.
The reopening marks a major milestone for the government agency, which mostly shuttered in-person services after the onset of the Covid-19 pandemic two years ago.
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During that time, the Social Security Administration pivoted mostly to online and phone services. However, many beneficiaries have complained about long waits on the agency's 800 number. Moreover, government inspections have highlighted the fact that the agency lacks formal procedures for processing mail, which has caused delays for some applications and services.
Even as offices reopen, people should still reach out online or by phone first, according to Kijakazi.
`` To avoid waiting in line, I strongly encourage people, who can, to use our online services at www.socialsecurity.gov, call us and schedule appointments in advance rather than walking in without an appointment, '' Kijakazi said. `` Phone appointments can save you a trip to a busy office. ''
If you show up at a Social Security office without an appointment, you may experience delays or longer wait times.
The offices tend to be busiest first thing in the morning, early in the week and early in the month, according to Kijakazi. `` People may want to plan to visit at other times, '' she said.
If you visit a Social Security office, you will be expected to comply with masking and physical distancing requirements. The agency also asks that visitors monitor their health for Covid-19 symptoms.
The Social Security Administration emphasizes that people who are seeking help or more information should first try the agency's website before calling or making an in-person office visit.
Services are available online at www.socialsecurity.gov. By also creating a My Social Security account, people can access personalized services that enable them to request a replacement Social Security card or SSA-1099 tax form, start or change direct deposits or print or download a benefit verification letter.
If you choose instead to use the agency's 800 number, you may still experience delays, due to a transition to a more modern phone system that is underway.
However, there are times when you may have more luck getting through, such as before 10 a.m., after 4 p.m. or later in the week. Wait times also tend to be shorter later in the month. | business |
Ukraine war, inflation and need for higher interest rates creating 'unprecedented ' situation, says Jamie Dimon | JPMorgan Chase & Co. CEO Jamie Dimon said the Western world faces “ challenges at every turn ” but the U.S. economy remains strong, according to his annual letter to shareholders.
JPMorgan’ s
JPM,
-1.39%
Dimon cited a myriad of difficulties, including unprecedented government actions, a strong recovery after a sharp and deep global recession, a highly polarized U.S. election, mounting inflation, a war in Ukraine and dramatic economic sanctions against Russia and an economic recovery in the wake of the COVID-19 pandemic.
The Russian sanctions could impact the bank’ s business by $ 1 billion over time, he revealed.
Despite these potential setbacks, Dimon said said the current times also offer an opportunity to “ put aside our differences, offer solutions and work with others in the Western world to come together in defense of democracy and essential freedoms, including free enterprise. ”
Separately JPMorgan also filed its
proxy statement
which disclosed Dimon’ s total compensation of $ 84.4 million for 2021, up from $ 31.7 million in 2020, according to the bank.
The latest figure includes $ 52.6 million in option awards for 2021, up from no option awards in 2020.
“ The special award granted to Mr. Dimon reflects the board’ s desire for him to continue to lead the firm for a further significant number of years, ” the company said. “ The board also took into account other factors, including the firm’ s strong performance under Mr. Dimon’ s stewardship since 2005, his exemplary leadership, and his significant contributions to the firm’ s success during his tenure. ”
Dimon’ s total annual compensation in 2021 rose to $ 34.5 million from $ 31.5 million in 2020 and 2019. The increase was due to a $ 3 million boost he received in performance share units ( PSUs) to $ 28 million in 2021 from $ 25 million.
His salary remained at $ 1.5 million.
Shares of JP Morgan Chase are down 14.6% so far in 2022, compared to a drop of 4.6% by the S & P 500 and a loss of 4.2% by the Dow Jones Industrial Average. The Financial Select Sector SPDR ETF
XLF,
-0.69%
is down 2.1%.
Russia’ s invasion of neighboring Ukraine and sanctions imposed on Russia by other world governments will slow the global economy — and things could get worse, Dimon said.
Adding persistent inflation that will require higher interest rates and a shift away from quantitative easing to quantitative tightening, and “ the confluence of these factors may be unprecedented, ” Dimon said.
The world was facing a range of other challenges before war broke out, including nuclear proliferation, cybersecurity risks, terrorism, climate change and vast inequities in society, he said.
That makes strong American leadership more crucial than ever.
“ Power abhors a vacuum, and it should be increasingly clear to all that without strong American leadership, chaos likely will prevail, ” he wrote.
Dimon said the bank’ s management looks past its short-term stock price because over time, the stock has outperformed. In the long run, its share price “ is a measure of the progress we have made over the years, ” he noted.
Also Read:
JPMorgan CFO feels ‘ really good’ about hitting the firm’ s ROTCE target
Dimon said he agreed with “ my friend, Warren Buffett ” ( CEO of Berkshire Hathaway
BRK.B,
-0.03%
) that his company’ s success is predicated upon the “ extraordinary conditions ” created by the U.S. government.
Dimon concluded his letter by crediting the bank’ s employees with “ guts, brains, integrity and enormous capabilities to navigate personally challenging circumstances while maintaining high standards of excellence. ”
In terms of the U.S. economy, the consumer “ is in excellent financial shape ( on average), with leverage among the lowest on record, excellent mortgage underwriting ( even though we’ ve had home price appreciation), plentiful jobs with wage increases and more than $ 2 trillion in excess savings, mostly due to government stimulus, ” he said.
Consumer spending over the last several months is 12% above pre-COVID-19 levels, while recognizing that the account balances in lower-income households, smaller to begin with, are going down faster and that income for those households is not keeping pace with rising inflation, he said.
Also read:
Banks are on high alert as White House flags potential Russian cyberattacks | business |
How fentanyl flooded the US and sent opioid deaths soaring | Erin McCormick examines what’ s driving a surge in drug overdose deaths in America – and why Black Americans, Indigenous Americans and young people have been so hard hit by the crisis
How to listen to podcasts: everything you need to know
Presented by Michael Safi with Erin McCormick and Perla Mendoza; produced by Courtney Yusuf, Lucy Hough, and Rudi Zygadlo; executive producers Mythili Rao and Phil Maynard
Mon 4 Apr 2022 03.00 BST
During the coronavirus pandemic, drug overdose rates in America surged. In 2020, overdoses were up by 31% in the US, according to the Centers for Disease Control and Prevention ( CDC). The death rate increased most dramatically among Black and Indigenous Americans – rising by 49% and 43% respectively in just one year.
Experts say a large portion of this increase can be explained by the growing prevalence of fentanyl, a potent synthetic opioid. The reporter Erin McCormick has been investigating how the drug became so widespread in the US, and how its rise is rewriting the narrative of America’ s opioid crisis.
According to a Guardian analysis of 2020 federal data, those under the age of 24 have been particularly hard hit in this latest wave of overdoses. Among this age group, accidental drug deaths increased by 50% in a single year – taking 7,337 young lives in 2020. One mother who has experienced this crisis firsthand is Perla Mendoza. She tells Michael Safi how her 20-year-old son, Daniel, overdosed on fentanyl after he was sold fake Xanax pills by a dealer on Snapchat.
The Guardian is editorially independent. And we want to keep our journalism open and accessible to all. But we increasingly need our readers to fund our work. | general |
Government to seek extension of public-sector pay deal | With inflation currently running at 5% at least, a review of the public sector pay deal has been triggered by the unions, and a successor deal is eagerly awaited, with unions demanding pay increases to match the rise in everyday costs. Picture shows frontline workers during the Covid crisis.
The Government is to seek an extension of the current public-sector pay deal as opposed to renegotiating a new agreement in full, warning unions that it “ can live without a deal ”.
Public Expenditure Minister Michael McGrath, in an interview with the Irish Examiner, has also warned that Ireland is just weeks away from housing thousands of Ukrainian refugees in large tents on State grounds.
As the country is entering into “ a very challenging period ”, given the extraordinary inflationary pressures on the Government, Mr McGrath said that extending the current pay deal is better than locking into a longer-term arrangement amid “ such uncertainty and volatility ”.
“ There is certainly a question to be answered as to whether this is an appropriate time to enter into a medium- to long-term agreement when you see inflation at the level it's at currently, '' he said.
`` And it's going to rise in the short term. This is an exceptional period. ”
“ There is merit in trying to reach an agreement that gets us through this particularly acute inflationary period, rather than a longer-term arrangement at a time with such uncertainty and volatility. ”
`` There is certainly an argument for seeking to reach an agreement, whether it be by means of an extension of the existing one, or entering a new one that gets us through what is an exceptional period without making longer-term decisions at this time. ''
The current public-sector pay deal, ‘ Building Momentum’, is due to lapse at the end of this year. It delivered a 3% pay increase for 345,000 State employees over the past two years.
With inflation currently running at 5% at least, a review of that deal has been triggered by the unions, and a successor deal is eagerly awaited, with unions demanding pay increases to match the rise in everyday costs.
Mr McGrath said his preference is that a deal with the unions can be agreed, but “ not at all costs ”.
“ So we can live without a deal, ” he said.
`` But it would be my preference to have a deal. Industrial peace is important. It's important for the country's reputation, but not at all costs. ''
In relation to Ukraine, Mr McGrath made it clear that he expects the country will very shortly run out of emergency accommodation, and the State will be forced to use tents to house refugees.
“ We are going to see Ukrainian refugees, unfortunately, having to be accommodated in circumstances that none of us would have thought imaginable, ” he said. | general |
Opinion: Pro-union votes at Amazon and Starbucks are wins for unconventional organizing -- - will they also revive the labor movement? | April 1, 2022, may go down as a pivotal day in the history of American unions.
In a result that could reverberate in workplaces across the U.S., the independent
Amazon Labor Union
– first
formed in 2020 by Chris Smalls
, an
Amazon worker fired
for protesting what he saw as inadequate COVID-19 safety precautions – got the better of the previously successful anti-union efforts of the online retailer
AMZN,
-2.11%
.
It means that Smalls’ warehouse in Staten Island, New York, will be
the first to have a unionized workforce
.
On the same day,
Starbucks Workers United
– an organization affiliated with Service Employees International Union – won yet another election, making it
10 out of 11 wins
for the union since
first succeeding in Buffalo
in December 2021. This time, it was the
chain’ s flagship roastery
in New York City that opted to unionize. The organizing campaign
has now spread
to over 170 Starbucks
SBUX,
-1.92%
stores nationwide. Several more Starbucks elections will take place in the coming weeks.
Meanwhile, a re-run election at a Amazon factory in Bessemer, Alabama, will
depend on the outcome of several hundred contested ballots
. Even if Amazon wins, the Retail, Wholesale and Department Store Union has – at very least – came tantalizingly close in what was deemed a long-shot union vote.
Something is definitely happening in the labor movement.
A different kind of organizing
As a
scholar of the labor movement
who has observed union drives for two decades, what I find almost as striking as the victories is the unconventional nature of the organizing campaigns. Both the Starbucks and Amazon-Staten Island campaigns have been led by
determined young workers
.
Inspired by pro-union sentiment in political movements, such as
Bernie Sanders’ presidential bids
,
Black Lives Matter
and the
Democratic Socialists of America
, these individuals are spearheading the efforts for workplace reform rather than professional union organizers. Indeed, one would be hard pressed to find many experienced organizers among the recent successful campaigns.
Instead, the campaigns have involved a significant degree of “ self-organization ” – that is, workers “ talking union ” to each other in the warehouse and coffee shops and reaching out to colleagues in other shops in the same city and across the nation.
This marks a sea change
from the way the labor movement has traditionally operated, which has tended to be more centralized and led by seasoned union officials.
A labor revival
Perhaps more important than the victories at Starbucks and Amazon themselves are their potential for creating a sense of optimism and enthusiasm around union organizing, especially among younger workers.
The elections follow
years of union decline in the U.S.
– both in terms of membership and influence.
Prior to the COVID-19 pandemic, these recent labor wins would probably have seemed unimaginable. Powerful, wealthy
corporations like Amazon
and Starbucks
appeared invincible then, at least in the context of
National Labor Relations Board
rules, which are stacked heavily
against pro-union workers
. Under NLRB rules, Amazon and Starbucks can – and do – force workers, on the threat of dismissal, to attend
anti-union sessions
, often led by
highly paid external consultants
.
Starbucks
has said it has been
“ consistent in denying any claims of anti-union activity. They are categorically false. ” But in March 2022, the NLRB alleged that the coffee chain had coerced workers, placed union supporters under surveillance and retaliated against them. Similarly Amazon – which has in the past
advertised for analysts to monitor “ labor organizing threats
” has said it
respects workers’ rights to join or not join unions
.
The significance of the recent victories is not primarily about the
8,000 new union members
at Amazon or a gradual flow of new union members at Starbucks. It is about instilling in workers the belief that if pro-union workers can win at Amazon and Starbucks, they can win anywhere.
Historic precedents show that labor mobilization can be infectious.
In 1936 and 1937, workers at the Flint plant of General Motors
brought the powerful auto-marker to its knees
in a sit-down strike that
quickly inspired similar action
elsewhere. In the reported words of a Chicago doctor, when explaining a subsequent sit-down strike by wet nurses in the city, “ It’ s just one of those funny things. They want to strike because everyone else is doing it. ”
Seizing the moment
The
pandemic has created an opportunity for unions
.
After working on the front lines for over two years, many essential workers such as those at Amazon and Starbucks
believe they have not been adequately rewarded
for their service during the pandemic and have not been treated with respect by their employers.
This appears to have helped spur
the popularity
of the Amazon Labor Union and Starbucks Workers United.
The homegrown nature of these campaigns deprives Amazon and Starbucks of employing a decades-old trope at the heart of corporate anti-union campaigns: that a
union is an external “ third party
” that doesn’ t understand or care about the concerns of employees and is more interested in collecting dues.
But those arguments mostly ring hollow
when the people doing the unionizing
are colleagues they work alongside day in and day out.
It has the effect of nullifying that central argument of anti-union campaigns despite the
many millions of dollars
that companies often pumped into them.
An unfavorable legal landscape
This “ self-organization ” at Starbucks and Amazon is consistent with what was envisioned by the authors of the
1935 Wagner Act
, the statute that provides the foundation of today’ s union representation procedures.
The National Labor Relations Board’ s first chair, J. Warren Madden, understood that self-organization could be fatally undermined if corporations were allowed to engage in anti-union pressure tactics:
“ Upon this fundamental principle – that an employer shall keep his hands off the self-organization of employees – the entire structure of the act rests, ”
he wrote
. “ Any compromise or weakening of that principle strikes at the root of the law. ”
Over the past half century, anti-union corporations and their consultants and law firms – assisted by
Republican-controlled NLRBs
and right-wing judges – have
undermined that process
of worker self-organization by enabling union elections to become employer-dominated.
But for the long-term decline in union membership to be reversed, I believe pro-union workers will need stronger protections. Labor law reform is essential if the
almost 50% of non-union American workers
who say they want union representation are to have any chance of getting it.
Dispelling fear, futility and apathy
Lack of popular interest
has long been an obstacle
to labor law reform.
Meaningful labor law reform is unlikely to happen unless people are engaged with the issues, understand them and believe they have a stake in the outcome.
But
media interest in the campaigns at Starbucks and Amazon
suggests the American public may finally be paying attention.
It isn’ t known where this latest labor movement – or moment – will lead. It could evaporate or it may just spark a wave of organizing across the low-wage service sector, stimulating a national debate over workers’ rights in the process.
The biggest weapons that anti-union corporations have in suppressing labor momentum are the fear of retaliation and a sense that unionization is futile. The recent successes show unionizing no longer seems so frightening or so futile.
John
Logan is a professor and the director of Labor and Employment Studies at San Francisco State University. This was first published by
The Conversation
— “
Amazon, Starbucks and the sparking of a new American union movement
“. | business |
Starbucks founder Schultz suspends share buybacks on return | The information you requested is not available at this time, please check back again soon.
Howard Schultz, chairman emeritus and former chief executive officer of Starbucks Corp., speaks during his 'From the Ground Up ' book tour in Washington, D.C., U.S., on Thursday, Feb. 14, 2019., Bloomberg
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Starbucks Corp. founder Howard Schultz suspended a share-buyback plan to mark the start of his latest spell as chief executive officer, saying the cash could be better spent on stores and staff.
The 68-year-old announced the move in a letter to the coffee chain’ s employees, the Seattle-based company said in a statement on Monday. It’ s “ the only way to create long-term value for all stakeholders, ” he said.
In October, Starbucks said it would spend US $ 20 billion on dividends and buybacks over three years, a decision that’ s now been partially revoked. Schultz’ s return, announced last month, comes at a challenging time for the global coffee chain, which faces a growing unionization effort at stores across the U.S. and a resurgent COVID-19 virus in the key growth market of China.
Through Friday, the stock fell 22 per cent this year, valuing the company at US $ 105 billion. Shares slipped a further 1.6 per cent in premarket trading in New York on Monday.
The founder is taking over from Kevin Johnson, who has run the firm since 2017. Schultz is serving on an interim basis while Starbucks seeks a permanent CEO. He will rejoin the board and handle day-to-day management in addition to helping with the search for a new leader, a process the company expects to complete by this fall.
Potential internal candidates for the top post include new operating chief John Culver and North America President Rossann Williams, Credit Suisse analyst Lauren Silberman has said. Other analysts have speculated that Schultz may end up staying on a longer-term basis.
Under Schultz, Starbucks grew from 11 stores to more than 28,000 across the globe, and now has 34,000. | general |
Tour of Flanders: Five conclusions from the men’ s race | Get access to more than 30 brands, premium video, exclusive content, events, mapping, and more.
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OUDENAARDE, BELGIUM - APRIL 03: ( L-R) Mathieu Van Der Poel of Netherlands and Team Alpecin-Fenix and Tadej Pogacar of Slovenia and UAE Team Emirates compete during the 106th Ronde van Vlaanderen - Tour des Flandres 2022 - Men's Elite a 272,5km one day race from Antwerp to Oudenaarde / # RVV22 / # WorldTour / on April 03, 2022 in Oudenaarde, Belgium. ( Photo by Tim de Waele/Getty Images) Photo: Getty
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First, we have to praise what went right, and for the majority of Sunday’ s epic edition of the Tour of Flanders, the debutant Tadej Pogačar was within touching distance of flawlessness. There was a small crash in the opening kilometers, but such episodes can happen to any rider, and when the race began to open up inside the final 80km, the Slovenian was constantly on the front foot and dictating the proceedings.
The youngster had clearly learned his lesson from Dwars door Vlaanderen when it came to timing, and that Flanders is a challenge best raced with an aggressive mindset. Pogačar’ s assaults on the Koppenberg and the final two ascents of the Kwaremont forged the key moves of the race. Everything else, from the early break dominated by Trek, Jumbo-Visma, and Quick-Step, was shown to be filler once Pogačar started to race.
An inability to distance van der Poel can’ t be labeled as a criticism — the Dutchman has won two of the last three editions of the race and finished second on the other occasion. However, where Pogačar’ s execution can be examined is his actions in the final kilometer.
Not taking a final pull on the front with just less than 1,000m to go was never going to determine Pogačar’ s eventual fate, but it did start a chain reaction that the Slovenian failed to understand, and ultimately reverse.
Pogačar’ s best hope of winning against van der Poel was always going to be via a long and drawn-out sprint against the Alpecin rider. The shorter the sprint, the greater the chances of van der Poel winning through his natural raw power. Pogačar’ s best window for victory was with around 250-300m to go, just before van Baarle and Maduous linked up with the leading pair. Had Pogačar accelerated just before the junction had been made, he could have possibly edged van der Poel. However, as soon as he let the chasers back into the fold, the sprint became far more complicated and Pogačar went from racing for second at worst, to an ill-fated fourth.
Van Baarle and Maduous both had momentum in the final straight, and the initial gap created by van der Poel indicated that victory was destined to be his. Yet when Maduous intelligently went for barriers, and van Baarle flicked to the opposite side, Pogačar became swamped and boxed in.
Even when van Baarle made his move there was still time for Pogačar to rescue a podium spot. The right choice would have been to change his line dramatically, even if it meant feathering the brakes, and then deviating to the wide space of road on the far left. However, as soon as he took his hands off the bars he was going to finish fourth.
Call it arm-chair tactics if you will, but this is what Robbie McEwen — one of the best sprinters of the 1990s and 2000s — had to say about it.
“ He got himself so squeezed in between the two but he really did make a, what you’ d have to call, with all due respect to Tadej Pogačar, a junior error coming into a sprint like that. You just can’ t afford to let riders come back with momentum like that. He did it to himself, I’ m sorry to say. It’ s another learning experience, maybe dropping back out of University and back to primary school when it comes back to a sprint for the finish. ”
Despite the fact that the Tour of Flanders was just his eighth day of competition this year, van der Poel has reached the near peak of his powers. In fact, one could easily argue that this is the best version of the Dutchman we’ ve ever seen. Not only does he possess the physical ability of a rider at the top of his career, but he’ s also racing with such a high level of maturity. He won his second edition of Flanders through brains and brawn, and several key moments stood out.
The first was that he didn’ t appear to panic when Pogačar attempted to blow the race apart on the Kwaremont with 55km to go. Kasper Asgreen, the rider who beat van der Poel in a two-man sprint in 2021, blew his engine trying to follow the UAE Team Emirates rider. Van der Poel’ s positioning when Pogačar took off on that first attack appeared suspect, but the Dutchman paced himself back to the front, and never let Pogačar out of his sight from that moment on. He matched Pogačar on the Koppenberg, and but for a split-second wobble on the Paterberg, was able to hold firm whenever the Slovenian pushed on the pedals.
The majority of the discussion around the sprint finish will naturally focus on how Pogačar lost the race. That’ s fair — the cycling world has rarely seen the young rider make a mistake, so eking out that fact will fill pages of discussion until Pogačar’ s ‘ has his revenge’ — assuming that’ s how sections of the media phrase it. However, all of that overshadows just how well van der Poel raced. He was present for all the key moves, he was the only rider able to follow the best climber in the race, and then he made Pogačar — McEwen’ s words, not ours — look like a junior in the sprint finish. Yes, Pogačar flubbed his lines, but it was van der Poel who wrote and delivered that script in the final 1,000m.
The Dutch outfit remained a major threat coming into the race, even with the loss of Wout van Aert from their roster. Teisj Benoot and Christophe Laporte had been in barnstorming form since the start of the year, but after COVID-19 took out their principal weapon there was always a question around Benoot’ s and Laporte’ s credentials. One of them had just two wins to his name, while the other was a decent but unprolific sprinter just a few months ago. Yes, Benoot had won Strade Bianche but there’ s a massive difference between 200km in early March, and the nearly 300km on some of the most unforgiving terrain that cycling has to offer. If there wasn’ t a significant difference then, Benoot — as good as he is — would have won more races by now.
Laporte’ s crash late in the race certainly had an impact in Flanders, but so too did sending both Nathan Van Hooydonck and Mick Van Dijke up the road in a break. It effectively isolated their two leaders after Affini had burned himself out. Laporte came back and snatched a respectable ninth, while Benoot battled to 13th. This was far from a disaster but the two riders found themselves on the back foot for most of the final two hours of racing and never looked like being major players once the Pogačar started blowing up the race on the second ascent of the Kwaremont. Jumbo-Visma were always chasing and eventually that left them empty-handed.
This has still been a hugely impressive spring for Jumbo-Visma, and if van Aert can regain his health for Paris-Roubaix then they’ ll be the team to beat yet again.
This has been an abysmal campaign for Patrick Lefevere’ s team, with Fabio Jakobsen’ s win in Kuurne papering over the cracks. Illness has been the go-to excuse for the Belgian squad but every unit in the WorldTour has suffered on that basis. One team boss told VeloNews on Sunday night that both of his entire rosters at Paris-Nice and Tirreno-Adriatico had come down with the bugs that have ravaged the European peloton this spring.
If Bahrain-Victorious and Groupama-FDJ — two squads that looked weaker on paper than QuickStep coming into this main block of racing — can animate a major race then why not Belgium’ s number one team? The fact is that several teams have stepped up in terms of their recruitment, while Lefevere’ s team has spread themselves too thin as they build around Alaphilippe and Evenepoel. The team hasn’ t bolstered their classics core in a number of years, and the likes of Zdeněk Štybar and Yves Lampaert have stagnated, either through age or a lack of form. It all means that if Kasper Asgreen is off-color there isn’ t anyone to step up. The results provide irrefutable answers with their best result through Gent-Wevelgem, Dwars door Vlaanderen, and Flanders coming through Jannik Steimle’ s 14th place in Wevelgem. That’ s not good enough for a team of such classic pedigree.
What will frustrate the management most of all is that despite Asgreen’ s clear lack of top-condition, no one else managed to fill the void, and the collective strength that was the mark of this team has been replaced by a collective sense of disappointment.
This is not a bad team, far from it, in fact. They have still won a remarkable 17 races this year, and they could still better their 60-plus tally from 2021. However, the spring classics have been a write-off thus far. It’ s perhaps a blessing that Paris-Roubaix has been moved a week later but at this point, it’ s still difficult to see where the turnaround will come and who can instigate it.
Van der Poel and Pogacar going head-to-head wasn’ t a massive surprise but there were a number of stand-out performances from a strong supporting cast.
Valentin Maduous has been one of the revelations of the cobbles campaign with the 25-year-old Frenchman epitomizing Groupama-FDJ’ s ever-improving classics squad. Maduous was present in every key move and was the last rider to crack when Pogačar made his final acceleration on the last ascent of the Kwaremont. Marc Madiot’ s man raced impeccably and even when he was distanced he still had the sense and grit to work with van Baarle in limiting their loses. Had they not done that then the fight for the final step on the podium would have come down to a two-up sprint rather than the pulsating four-man effort. Along with Stefan Küng, Olivier Le Gac, and Kevin Geniets the team has a formidable unit heading it Paris-Roubaix.
Fred Wright also deserves high praise for his spirited effort. The British rider and his teammates were at the front when it mattered most with several key attacks in the final 45km. Wright was re-signed by Bahrain-Victorious over the winter and through the demonstration he provided on Sunday, it was a wise decision.
Van Baarle is no spring chicken at 29, but he came back from a double mechanical and still secured second. He has looked very consistent over the spring and could well pull off another major result as the spring opens up.
Finally, a word on Robbie McEwen. The Australian was let go over the winter by a home broadcaster, but has made an instant impression at Eurosport over the last few weeks. It’ s’ not just his expert knowledge of the Belgian roads and culture, but just the way he can explain the race situation to both newcomers and more educated fans without alienating or confusing either group. He naturally compliments whoever he’ s in the commentary booth with, and should be invited back throughout the rest of the spring and at the grand tours.
Get the latest race news, results, commentary, and tech, delivered to your inbox. | general |
Children with Covid in Shanghai reportedly separated from parents – video | Footage circulating on social media purports to show children who have Covid crying after allegedly being separated from their parents and placed into quarantine at a clinic in Shanghai. An unverified clip shows babies and toddlers placed together in rooms and cots, as the city battles a surge of the virus
Mon 4 Apr 2022 16.27 BST Last modified on Mon 4 Apr 2022 16.41 BST | general |
Twitter shares jump as Elon Musk takes 9.2% stake; UK household income squeeze ‘ to tighten’ – as it happened | Rolling coverage of the latest economic and financial news
Graeme Wearden
Mon 4 Apr 2022 17.23 BST First published on Mon 4 Apr 2022 08.09 BST
From 2.16pm BST
14:16
The billionaire Elon Musk has taken an almost $ 3bn ( £2.3bn) stake in Twitter to become the social media platform’ s largest shareholder.
The world’ s richest man, who has a penchant for eccentric behaviour frequently involving posts on Twitter, has built a 9.2% stake in Twitter, according to filings made to the US Securities and Exchange Commission ( SEC) on Monday.
The boss of Tesla and SpaceX, who with more than 80 million followers ranks in the top 10 most popular Twitter users globally, paid $ 2.89bn for the stake at Twitter’ s closing share price on Friday.
Shares in the microblogging site soared as much as 26% in pre-market trading on the back of the news, adding more than $ 8bn to its $ 31.5bn market value before Musk’ s interest was made public. After the stock price jump Musk’ s shares are now worth about $ 3.6bn.
Musk, who just last week said he was “ giving serious thought ” to building his own social media platform, now holds a stake more than four times the 2.25% holding of the Twitter co-founder Jack Dorsey
Updated at 2.17pm BST
5.19pm BST 17:19
Time for a recap.
Elon Musk has taken a 9.2% stake in Twitter that appears to make him its biggest shareholder.
Regulatory filings show that Musk hit the mark on 14th March, days before he criticised Twitter’ s online moderation for not protecting free speech, saying that he was “ giving serious thought ” to building a new platform.
Shares in Twitter surged 20%, with analysts predicting that Musk could become an acticist investor pushing for change, or even launch a buyout.
Elon Musk’ s $ TWTR stake is sparking speculation he could take more action to shake up the company '' Musk isn’ t here to make $ 500m or $ 1bn or $ 2bn. Nor does he figure to remain passive. Musk is a threat to do almost anything at TWTR so use your imagination ” https: //t.co/62TULTDuqv
Walid Koudmani, chief market analyst at financial brokerage XTB, says:
“ While Elon Musk has been critical of the social media platform, this could be a key development for the company as its share price had been struggling for some time. ”
Here’ s the full story:
UK consumer confidence has slumped, as rising inflation forces families to cut back on disposable spending as they struggle to meet food and energy bills.
Bank of England deputy governor Sir Jon Cunliffe has predicted that the Ukraine crisis will intensify and prolong the surge in inflation and tighten the squeeze on household incomes.
Grim chart from @ bankofengland Deputy Governor Jon Cunliffe that underlines why 2022 is going to be a dreadful year for least well-off. 👇 pic.twitter.com/M4V4Na1pRY
Supermarket chain Morrisons warned its profits are likely to take a significant hit this year as the cost of living crisis and disruption due to the war in Ukraine weigh on the grocery market.
Inflation is roaring away in Turkey too, where consumer prices jumping by over 60% in the last year due to the tumbling lira, and rising food and energy costs.
Berlin has taken temporary control of Gazprom’ s German operations, in an attempt to ensure security of energy supplies.
The move came as top bankers warned that Germany will face a steep recession if imports of Russian gas and oil stopped.
Orders at US factories dropped for the first time in 10 months in February, in a sign that the global economy is slowing.
The slowdown continued in March, with global manufacturing growth hitting an 18-month low as the Russia-Ukraine war and the ongoing Covid-19 pandemic hit the sector.
German trade picked up in February, but imports and exports with Russia dropped in an early sign of the economic consequences of the Ukraine war.
JP Morgan chief executive, Jamie Dimon, has warned that the US bank could lose up to $ 1bn ( £763m) from its exposure to Russia. Dimon also urged the US government to deploy more troops, restructure supply chains and launch a new “ Marshall plan ” to ensure energy supply in response to the war in Ukraine.
Chancellor Rishi Sunak has asked the Royal Mint to create a non-fungible token ( NFT) to be issued by this summer. The move will hardly help the cost of living crisis, but will ( apparently) show the UK’ s ‘ forward-looking approach’ to crypto.
Bank of England chief Andrew Bailey has a more critical approach - warning today that cryptocurrencies are the new “ front line ” in criminal scams.
Mauricio Magaldi, global strategy director for crypto at fintech consultancy 11: FS, says:
“ The news that the Treasury will be launching NFTs later this year seems to be nothing more than a strategic PR-play. However, talk of the UK becoming a ‘ crypto hub’ seems to hold much more promise and is a welcome change from their previously limited stance.
“ The next steps will paint the bigger picture and determine whether we see actual investment in creating dialogue for a regulatory framework that fosters the crypto economy in the UK. ”
There has been chaos at some airports, as EasyJet and British Airways were forced to cancel flights because of high levels of Covid-19 infections among staff.
The disruption follows rising UK case numbers after the removal of almost all pandemic restrictions.
A train breakdown in the Eurotunnel has added to the misery for passengers.
The bus network has also been undermined, with more than one in four bus services in England have been cut in the last decade.
More than 3,000 workers at 60 companies across Britain will trial a four-day working week, in what is thought to be the biggest pilot scheme to take place anywhere in the world.
The UK’ s financial regulators are investigating the London Metal Exchange’ s handling of a week-long suspension of trading in nickel amid chaotic conditions at the start of Russia’ s invasion of Ukraine.
Spanish police and US FBI agents have searched a £70m superyacht in Mallorca linked to Viktor Vekselberg, a sanctioned Russian billionaire the US government says is a close ally of Vladimir Putin...
... while Roman Abramovich’ s $ 600m ( £458m) superyacht Solaris has left a port in Turkey after the London-based company that operates the terminal which had been harbouring the oligarch’ s yacht was pressed to act.
Goodnight. GW
Updated at 5.23pm BST
5.16pm BST 17:16
Sarah Butler
Morrisons has warned its profits are likely to take a significant hit this year as the cost of living crisis and disruption due to the war in Ukraine weigh on the grocery market.
The UK’ s fourth largest supermarket chain said “ developments in the geopolitical environment ” and “ ongoing and increasing inflationary pressure ” since the beginning of February were hitting consumer sentiment and spending.
It said it was difficult to predict how long the problems would last, and that unless conditions improved, it could face a “ material adverse effect ” on sales and earnings for the year.
Food and drink businesses have been particularly hit by the energy crisis, and rising raw material costs, according to new data from the ONS this morning:
60% of food and beverage businesses reported being affected by rising energy prices in March, compared with 38% across all sectors. They were also more likely to cite concerns on inflation and energy prices compared with businesses across all sectors https: //t.co/hiSnkhKEk3 pic.twitter.com/OS94aut4Qk
5.14pm BST 17:14
Back in the City, the FTSE 100 index of blue-chip shares has ended the day 21 points higher at 7558, up 0.3%.
Housebuilders were among the risers, following reports that the government was close to agreeing a deal on the cladding crisis that wouldn’ t immediately hit developers with a £4bn bill to fix problems following the Grenfell Tower disaster.
Danni Hewson AJ Bell financial analyst, explains:
Housebuilders have been in the doldrums since the start of the year despite a supercharged housing market as investors priced in the cost of making repairs. The deal on the table would require companies to deal with issues on any medium rise building they’ ve built over the last thirty years, but additional funding talks would be put off until later in the year.
The long running dispute about who should foot the bill to deal with fire safety issues has been contentious and housebuilders will need to act quickly to show they’ re serious about making things right.
Industrial software group Aveva ( +4%) and gambling firm Flutter ( +3.9%) led the gainers.
But banks and miners led the fallers, reflecting concerns that the global economy could be heading for a weaker patch.
European stocks rallied, with Germany’ s DAX up 0.5%. and France’ s CAC 0.7% higher.
5.08pm BST 17:08
Neil Campling, head of TMT research at Mirabaud Equity Research, says Twitter’ s executives face a tougher ride now Elon Musk is top of their shareholder register.
“ Just a week ago, Musk complained that Twitter didn’ t adhere to the principles of free speech. And now he takes a 9.2% stake. It is described as a “ passive stake ” but given how Musk likes to air his views on the platform, he is unlikely to stay passive for long.
The new CEO has only just settled into the seat, but so far has only really issued goals of revenue growth and user growth ( which aren’ t any different from previous head Jack Dorsey) without real substance of how they can be achieved. His job has just got a whole lot tougher, as Musk loves to air his views.
And Twitter doesn’ t have the multiple share classes ( those that give protections to the likes of Zuckerberg at Facebook and Spiegel at Snap) so there is nowhere for the Twitter executives to hide if Musk goes on the attack. ”
4.47pm BST 16:47
In Germany, regulators have taken temporary control of Gazprom Germania, an energy trading, storage and transmission business.
Gazprom Germania, which its parent company Gazprom abandoned late last week, will be transferred to Germany’ s regulator to ensure energy security, Economy Minister Robert Habeck said on Monday.
BREAKING: Germany takes over a key European unit of Russian state-owned gas giant Gazprom, effectively nationalizing the unit until at least Sept. 30 ( In legal terms, the unit, called Gazprom Germania GmbH, is put under the trusteeship of the German energy regulator) # ONGT
Habeck told a news conference that the temporary measure would guarantee security of energy supplies:
“ The order of the trust administration serves to protect public security and order and to maintain the security of supply. This step is mandatory. ”
Klaus Mueller, head of the Bundesnetzagentur regulator, said:
Our goal will be to run Gazprom Germania in the interests of Germany and Europe.
NEW: Official notice from German Government of seizure of Gazprom Germany and all voting rights, ability to appoint board, after change of ownership in Russia to unidentifiable owners “ Palmary ” and attempt to liquidate, justified on basis of ownership of “ critical infrastructure ” pic.twitter.com/4LiE7CLlcz
Germany also continues to resist calls for an immediate ban on Russian gas exports to Europe, following reports of atrocities and war crimes in Ukraine, where the bodies of hundreds of civilians have been found in towns near Kyiv.
German Finance Minister Christian Lindner argued that such sanctions would hurt the EU more than Russia. Speaking before today’ s Eurogroup meeting of eurozone finance ministers, Lindner said:
“ We are dealing with a criminal war.
It is clear we must end as quickly as possible all economic ties to Russia. We must plan tough sanctions, but gas can not be substituted in the short term. We would inflict more damage on ourselves than on them. ”
Wholesale gas prices have dropped around 8% today, with the UK day-ahead contract falling to 231p -- over four times its level a year ago.
Updated at 4.49pm BST
4.33pm BST 16:33
Orders at US factories have dropped for the first time in 10 months, in a sign that the global economy is slowing.
Manufactured goods orders fell 0.5% in February, the US Commerce Department reports, the first monthly drop in factory orders since April 2021.
Orders for heavy-duty “ durable goods ” ( such as cars, kitchen appliances and computers) fell 2.1% in February, led by a 5.3% drop in orders for transportation equipment.
Nondurable goods orders rose 1.2%, but the closely-watched orders for nondefense capital goods, excluding aircraft, fell 0.2% in February.
Feb factory orders -0.5% vs. -0.6% est. & +1.5% in prior month ( rev up from +1.4%); worst monthly decline since April 2020 … y/y gains off peak but remain healthy for now at +12.6% pic.twitter.com/RzydAMYvxo
In another sign that the economy is slowing, factory orders declined 0.5% in February to $ 542B after nine straight months of increases. pic.twitter.com/LqbdFCkQXo
4.24pm BST 16:24
Join Hugh Muir, Richard Partington, Anneliese Dodds MP and youth campaigner Christiana Adane, in a livestreamed event on the cost of living crisis and the effect on the poorest households on Thursday 14 April 2022, 8pm BST. Book tickets here
4.22pm BST 16:22
Grim chart from @ bankofengland Deputy Governor Jon Cunliffe that underlines why 2022 is going to be a dreadful year for least well-off. 👇 pic.twitter.com/M4V4Na1pRY
BoE's Cunliffe explains why he voted to leave rates on hold. He doesn't see much evidence of high inflation becoming embedded in the public psychology. `` We should not talk ourselves into into believing we are inevitably heading for a repeat performance ( of the 1970s) '' he says pic.twitter.com/2IfI9nxAuX
3.35pm BST 15:35
Bank of England deputy governor Sir John Cunliffe has warned that Russia’ s invasion of Ukraine will tighten the UK’ s cost of living crisis.
Speaking at the European Economics & Financial Centre this afternoon, Cunliffe points out that the conflict has already pushed up the cost of energy, and other raw materials such as metals and fertiliser.
Global oil prices have increased by 11% and UK wholesale gas prices have increased by 40% since the invasion, Cunliffe explains.
It is likely that prices of energy and commodity prices will be higher for longer, he says, which will push up on inflation and down on GDP in advanced economies such as the UK.
Cunliffe says:
Much will depend on the course of the conflict and the evolution of sanctions. But in all probability, it will intensify and prolong the surge in inflation and tighten the squeeze on household incomes.
The consequent drop in demand through household consumption and business investment will, to an extent not yet clear, be greater than we thought in February. And there are also likely to be additional impacts on the supply side of the economy.
He also points out that poorer families will be hit hardest by higher energy prices ( as they have less savings to cushion the impact).
Cunliffe was the only BoE policymaker to oppose last month’ s interest rate rise. And today, he pushes back against fears that the UK is facing a repeat of the wage-price spirals of the 1970s.
At the last MPC meeting, shortly after the invasion, I voted against increasing rates. This was not because I take the first risk lightly. As the oldest member of the MPC ( by some way) I remember very well indeed the extreme manifestation of such an inflation psychology, which characterised the 1970s. I remember also the cost of correcting it. But I do not think we are yet seeing a psychology of persistently higher inflation emerge.
The predominant driver of the growth we have seen in pay has been the tightness of the labour market. There may also now be some element of catching up with inflation that has already happened.
3.19pm BST 15:19
Ben Laidler, global markets strategist at social investment network eToro, says Musk is diversifying his investments by taking a 9.2% stake in Twitter.
This is a significant public step in diversifying his investments away from major holdings like Tesla ( TSLA) and SpaceX. It has triggered a Twitter share price surge, and focused attention across the long-suffering social media sector, from Meta ( FB) to Snap ( SNAP).
“ Warren Buffett famously encourages investments in ‘ what you know’, and Elon Musk knows Twitter very well. He has 80 million followers on the platform, has made over 17,000 tweets since joining in 2009, and recently publicly criticised the company for its free speech policy.
“ It remains to be seen what Musk plans for his stake, which is four times the size of founder Jack Dorsey. Twitter has only recently seen Dorsey step down as CEO in November last year, under pressure from famed activist investor Elliott Management. ”
Musk’ s stake is now worth around $ 3.5bn, from $ 2.89bn on Friday night, after today’ s share price jump.
3.07pm BST 15:07
Twitter shares have jumped by a fifth in early trading, after Elon Musk took a 9.2% stake in the company.
The stock is up 20.3%, or around $ 8, at $ 47.30, as investors wonder what Musk’ s plans may be.
That lifts Twitter’ s market capitalisation from around $ 31.4bn to $ 37.8bn.
When taking a step back, Twitter was approaching a 52-week low. It is just crazy to think that Elon Musk buying a stake in Twitter makes the stock rise by 20%. It is a passive investment in Twitter, so what changed fundamentally with the company? Or maybe I am missing something. pic.twitter.com/hnG6SOxBLJ
CNBC says:
While it is classified as a passive stake, investors were bidding shares higher on the chance this could lead to something more. Twitter stock surged more than 21% in the morning.
Updated at 3.08pm BST
2.55pm BST 14:55
Bank of England governor Andrew Bailey struck a more cautious approach to cryptocurrencies today - warning they are the new “ front line ” in criminal scams.
Bloomberg has the details:
Speaking at a “ Stop Scams ” conference organized by the U.K. central bank, Bailey said that the underlying technology of crypto is contributing a good deal of innovation to financial services, but also created an “ opportunity for the downright criminal. ”
“ You only have to ask the question: What do people committing ransom attacks usually demand payment in? The answer is crypto, ” he said.
The U.K.’ s financial regulator, the Financial Conduct Authority, last week extended a deadline for its approval of crypto operations. That gave a dozen firms more time to get their applications or affairs in order. So far, 33 have been approved for permanent registration with the FCA, which allows them to continue providing cryptocurrency services from within the U.K. after April 1.
2.50pm BST 14:50
Chancellor Rishi Sunak has asked the Royal Mint to create a non-fungible token ( NFT) to be issued by this summer.
I initially thought was a belated April Fool’ s joke, but according to the Treasury it shows the UK’ s ‘ forward-looking approach’ towards cryptoassets.
Chancellor @ RishiSunak has asked @ RoyalMintUK to create an NFT to be issued by the summer.This decision shows the the forward-looking approach we are determined to take towards cryptoassets in the UK. pic.twitter.com/cd0tiailBK
NFTs give people ownership of digital assets, such as a piece of digital art, by registering them on a blockchain.
Perhaps the UK’ s design should show a struggling family who can’ t afford to heat their homes.
Rishi Sunak has asked the Royal Mint to create a non-fungible token, City Minister @ JohnGlenUK says.The NFT will be `` an emblem of the formal approach we are determined to take '' on regulating crypto.
The Treasury have also said the UK plans to legislate to regulate some stablecoins - cryptocurrencies pegged to traditional currencies or assets - when they are used as a means of payment.
UK financial services minister John Glen outlined the plan to UK Fintech Week today, saying ( via Reuters):
“ We have a detailed plan... this is a new world for the newly regulated and the regulators.
Economic Secretary @ JohnGlenUK announced today that stablecoins will be brought into UK payments regulation.This places the UK financial services sector at the forefront of technology, creating conditions for stablecoin issuers and service providers to operate and invest. pic.twitter.com/14SsIGW5bf
Updated at 3.44pm BST
2.19pm BST 14:19
Kalyeena Makortoff
The JP Morgan chief executive, Jamie Dimon, has warned that the US bank could lose up to $ 1bn ( £763m) from its exposure to Russia, as he called on the US government to deploy more troops, restructure supply chains and launch a new “ Marshall plan ” to ensure energy supply in response to the war in Ukraine.
In his widely read annual letter to investors, Dimon urged Joe Biden’ s administration to take a stronger stance against the “ grave new geopolitical realities ” emerging after Russia’ s invasion of Ukraine, saying it was up to democratic nations to take a stand “ against all forms of evil ”.
Dimon, who is one of the most high-profile bosses to comment on the conflict so far, also detailed the bank’ s potential $ 1bn losses because of its direct exposure to Russia. JP Morgan announced it was winding down its Russia operations – which employ about 160 staff – last month.
He wrote:
“ As I write this letter, the war in Ukraine has been raging for well over a month and is creating a significant refugee crisis. We do not know what its outcome ultimately will be, but the hostilities in Ukraine and the sanctions on Russia are already having a substantial economic impact.
They have roiled global oil, commodity and agricultural markets. ”
However, Dimon said the war’ s wider impact, including the “ potential restructuring of the global order – is far more important ”.
Noting that the war could impact geopolitics for decades, he added: “ We must confront the Russia challenge with bold solutions. ”
2.16pm BST 14:16
The billionaire Elon Musk has taken an almost $ 3bn ( £2.3bn) stake in Twitter to become the social media platform’ s largest shareholder.
The world’ s richest man, who has a penchant for eccentric behaviour frequently involving posts on Twitter, has built a 9.2% stake in Twitter, according to filings made to the US Securities and Exchange Commission ( SEC) on Monday.
The boss of Tesla and SpaceX, who with more than 80 million followers ranks in the top 10 most popular Twitter users globally, paid $ 2.89bn for the stake at Twitter’ s closing share price on Friday.
Shares in the microblogging site soared as much as 26% in pre-market trading on the back of the news, adding more than $ 8bn to its $ 31.5bn market value before Musk’ s interest was made public. After the stock price jump Musk’ s shares are now worth about $ 3.6bn.
Musk, who just last week said he was “ giving serious thought ” to building his own social media platform, now holds a stake more than four times the 2.25% holding of the Twitter co-founder Jack Dorsey
Updated at 2.17pm BST
1.05pm BST 13:05
Here’ s Associated Press’ s take on Tesla CEO Elon Musk taking a 9.2% stake in Twitter:
Musk’ s stake in Twitter is considered a passive investment, which means Musk is a long-term investor that’ s looking to minimize his buying and selling of the shares.
Yet in recent weeks Musk has raised questions about free speech on Twitter and if failing to adhere to its basic principles undermines democracy.
He has also pondered starting up a rival social media network and industry analysts are skeptical about whether the mercurial CEO would remain on the sidelines for long.
“ We would expect this passive stake as just the start of broader conversations with the Twitter board/management that could ultimately lead to an active stake and a potential more aggressive ownership role of Twitter, ” Dan Ives of Wedbush Securities said in a client note early Monday.
12.44pm BST 12:44
Elon Musk’ s surprise Twitter stake is a ‘ major test’ for the social media company’ s chief executive Parag Agrawal, says Bloomberg:
Musk has been one of the biggest personalities on Twitter and has regularly run into trouble on the platform.
The Tesla Inc. chief executive officer is currently seeking to exit a 2018 deal with the U.S. Securities and Exchange Commission that put controls in place related to his tweeting about the electric-car maker.
Bloomberg adds:
The announcement will be yet another major test for new Twitter CEO Parag Agrawal, who replaced Jack Dorsey after he unexpectedly resigned in November.
Agrawal vowed to increase accountability, make decisions faster and to improve product execution. The company set ambitious goals for growth including increasing annual revenue to $ 7.5bn and getting to 315 million daily users by the end of 2023.
It's never quiet in Musk-land: Elon Musk is now the biggest shareholder @ Twitter after taking a 9.2% stake. That's a week after hinting about plans to shake up the social media platform. https: //t.co/ErEmnwpqR9 via @ technology
12.35pm BST 12:35
Elon Musk is now Twitter’ s biggest shareholder, according to data on our Refinitiv terminal.
Musk’ s 9.2% stake puts him ahead of investment group The Vanguard Group ( with 8.79%), Morgan Stanley Investment Management ( 8.08%) and BlackRock Institutional Trust Company ( 4.56%).
Twitter co-founder Jack Dorsey still owns around 2.25% of its stock, or around a quarter of Musk’ s stake.
I guess that makes @ elonmusk Twitter’ s largest shareholder — bigger than even Dorsey pic.twitter.com/21rLe1tkun
Updated at 12.37pm BST | general |
Less can be more with hyper-personalization | We are excited to bring Transform 2022 back in-person July 19 and virtually July 20 - 28. Join AI and data leaders for insightful talks and exciting networking opportunities. Register today!
Too often, customers are being inundated with messages from the companies they do business with. Marketing messaging was anticipated to increase 40% last year, and there are no signs of slowing down. But too often we’ re seeing quantity take precedence over quality, and that’ s not sustainable. In today’ s environment, less than more.
Customers want information that’ s relevant to them and that’ s customized for their unique needs even as those rapidly change from day to day. Think about how Netflix provides recommendations of what to watch next based on what you’ ve already viewed or the way Amazon provides suggested items to buy based on your prior searches and purchases. Their algorithms are continuously learning and serving up new recommendations based on your behaviors — not just shoving random information at you. These are forms of hyper-personalization, in which AI and real-time data are used to deliver more relevant content, product and service information to each customer. That’ s what customers want — 80% say they prefer to patronize brands that offer personalized experiences.
Personalization has proven to yield 20% higher customer satisfaction rates and a 10% to 15% boost in sales conversion rates in retail, and according to HubSpot, personalized calls to action have a 202% better conversation rate than default or standard calls to action.
These findings speak volumes. The old, static transactional nature of customer engagement won’ t suffice any longer — and it shouldn’ t.
When you truly personalize your communications for each customer, messages are more likely to resonate with the customer’ s unique and evolving needs to create a consistently positive brand experience. That goes a long way toward improving customer experience, and as a result, loyalty and retention.
Hyper-personalization is more than simple customization like including a customer’ s name in an email or text — that type of generalized personalization helps grab attention but it’ s not enough. It needs to be based on not just customer preferences, but customer habits. And it needs to be done in a rapid, continuous fashion because customer needs and attention spans change quickly — you have to be able to adapt to those changes just as speedily.
Looking at things such as whether they respond better in the morning or evening, on weekdays or weekends, and if they respond better to email or text messages are just the starting point.
Other areas to focus on can include:
Using multiple aspects of personalization can create a multiplier effect – optimizing your interactions further and further. All of this takes a continuous approach. Hyper-personalization is refined by identifying and validating patterns in behavior and continuously testing and adjusting the next interaction based on what was learned from the last interaction with that customer. For effective digital engagement, you need to be able to continuously learn and rapidly apply your findings. Adaptation is the name of the game.
But many organizations have struggled with this; many of the available tools only offer a solution for one piece of the puzzle. Some will help you with the actual sending of messages to customers. Others are more of a service, where they might help you customize a campaign for your marketing plan or whatever engagement projects you want to do. But there aren’ t many solutions that bring these elements together to enable you to do all of this in a much more systematic and continuous way.
Customers’ needs, wants and desires, sentiment and expectations are changing almost constantly. You need a solution that will enable you to continuously adapt and iterate in response to these changes. Hyper-personalization is not “ one and done. ”
To work effectively, hyper-personalization needs to be interactive and dynamic. As an example, let’ s say you have two customers — Sarah and Sam — to whom you want to promote a new auto-loan product. You send them both the same message initially. Sam is intrigued, opens the message and is then considering a new vehicle purchase. But Sarah ignores it; the message doesn’ t resonate with her. From there, you must tweak the approach — what works for Sam isn’ t going to work for Sarah — and you must do this quickly to find the best way to engage. That requires trial and error.
With COVID-19 and the rapid changes it brought, many companies are struggling with finding enough time to really learn about their customers from scratch. McKinsey found that organizations that use technology to revamp customer experience can increase customer satisfaction by 15 to 20%.
At the same time, organizations are also grappling with the rise of digital fatigue — customer attention spans are decreasing, so you need to be able to rapidly iterate. In a Symend survey conducted last year, 49% of respondents said they were experiencing digital fatigue. And digital fatigue is amplified by what’ s called habituation — resulting in a weakened response from repeated exposure to a company’ s messages. If a consumer receives repetitive communications from their provider, they’ re likely to “ habituate ” to them and therefore be less likely to read or act on those messages. This means you can’ t wait weeks or months to make changes or corrections based on an initial interaction.
Time is of the essence and you can’ t rely on static, outdated data to help you make those changes as quickly as they need to be made. It’ s critically important for a business to truly understand their users in real time and offer them the best solution for their needs — while also recognizing that real-time data alone isn’ t enough; the rule sets and algorithms must also be dynamic.
What organizations need is a solution that’ s already been tested, that has made the mistakes and can give them what they need now – one that allows for frequent tweaks to get the desired outcome. It’ s less about adding new ways of engaging and more about using the same method in new or different ways to really make things personalized to each individual user. Even a little hyper-customization can go a long way.
Quantity over quality won’ t win the game. Customers don’ t want to be hit with message after message that’ s not relevant to them. They want engagement that’ s personalized for them — in terms of content and how it’ s framed, tone, timing and delivery method. That’ s the heart of hyper-personalization. Work with a technology solution that enables you to send fewer but more relevant messages to deliver real customer engagement that improves customer experience — and, ultimately, your bottom line.
PehKeong Teh is chief product officer of Symend.
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Jamie Dimon says inflation, Ukraine war may dramatically increase risks for U.S. | In this article
Jamie Dimon, CEO and chairman of the biggest U.S. bank by assets, pointed to a potentially unprecedented combination of risks facing the country in his annual shareholder letter.
Three forces are likely to shape the world over the next several decades: a U.S. economy rebounding from the Covid pandemic; high inflation that will usher in an era of rising rates, and Russia's invasion of Ukraine and the resulting humanitarian crisis now underway, according to Dimon.
`` Each of these three factors mentioned above is unique in its own right: The dramatic stimulus-fueled recovery from the COVID-19 pandemic, the likely need for rapidly raising rates and the required reversal of QE, and the war in Ukraine and the sanctions on Russia, '' Dimon wrote.
`` They present completely different circumstances than what we 've experienced in the past – and their confluence may dramatically increase the risks ahead, '' he wrote. `` While it is possible, and hopeful, that all of these events will have peaceful resolutions, we should prepare for the potential negative outcomes. ''
Dimon's letter, read widely in business circles because of the JPMorgan CEO's status as his industry's most prominent spokesman, took a more downcast tone from his missive just last year. While he wrote extensively about challenges facing the country, including economic inequality and political dysfunction, that letter broadcast his belief that the U.S. was in the midst of a boom that could `` easily '' run into 2023.
Now, however, the outbreak of the biggest European conflict since World War II has changed things, roiling markets, realigning alliances and restructuring global trade patterns, he wrote. That introduces both risks and opportunities for the U.S. and other democracies, according to Dimon.
`` The war in Ukraine and the sanctions on Russia, at a minimum, will slow the global economy — and it could easily get worse, '' Dimon wrote. That's because of the uncertainty about how the conflict will conclude and its impact on supply chains, especially for those involving energy supplies.
Dimon added that for JPMorgan, management isn't worried about its direct exposure to Russia, though the bank could `` still lose about $ 1 billion over time. ''
Here are excerpts from Dimon's letter.
`` We expect the fallout from the war and resulting sanctions to reduce Russia's GDP by 12.5% by midyear ( a decline worse than the 10% drop after the 1998 default). Our economists currently think that the euro area, highly dependent on Russia for oil and gas, will see GDP growth of roughly 2% in 2022, instead of the elevated 4.5% pace we had expected just six weeks ago. By contrast, they expect the U.S. economy to advance roughly 2.5% versus a previously estimated 3%. But I caution that these estimates are based upon a fairly static view of the war in Ukraine and the sanctions now in place. ''
`` Many more sanctions could be added — which could dramatically, and unpredictably, increase their effect. Along with the unpredictability of war itself and the uncertainty surrounding global commodity supply chains, this makes for a potentially explosive situation. I speak later about the precarious nature of the global energy supply, but for now, simply, that supply is easy to disrupt. ''
`` America must be ready for the possibility of an extended war in Ukraine with unpredictable outcomes. … We must look at this as a wake-up call. We need to pursue short-term and long-term strategies with the goal of not only solving the current crisis but also maintaining the long-term unity of the newly strengthened democratic alliances. We need to make this a permanent, long-lasting stand for democratic ideals and against all forms of evil. ''
`` Russian aggression is having another dramatic and important result: It is coalescing the democratic, Western world — across Europe and the North Atlantic Treaty Organization ( NATO) countries to Australia, Japan and Korea. [ … ] The outcome of these two issues will transcend Russia and likely will affect geopolitics for decades, potentially leading to both a realignment of alliances and a restructuring of global trade. How the West comports itself, and whether the West can maintain its unity, will likely determine the future global order and shape America's ( and its allies ') important relationship with China. ''
`` It also is clear that trade and supply chains, where they affect matters of national security, need to be restructured. You simply can not rely on countries with different strategic interests for critical goods and services. Such reorganization does not need to be a disaster or decoupling. With thoughtful analysis and execution, it should be rational and orderly. This is in everyone's best interest. ''
`` For any products or materials that are essential for national security ( think rare earths, 5G and semiconductors), the U.S. supply chain must either be domestic or open only to completely friendly allies. We can not and should not ever be reliant on processes that can and will be used against us, especially when we are most vulnerable. For similar national security reasons, activities ( including investment activities) that help create a national security risk — i.e., sharing critical technology with potential adversaries — should be restricted. ''
`` This restructuring will likely take place over time and does not need to be extraordinarily disruptive. There will be winners and losers — some of the main beneficiaries will be Brazil, Canada, Mexico and friendly Southeast Asian nations. Along with reconfiguring our supply chains, we must create new trading systems with our allies. As mentioned above, my preference would be to rejoin the TPP — it is the best geostrategic and trade arrangement possible with allied nations. ''
`` The Federal Reserve and the government did the right thing by taking bold dramatic actions following the misfortune unleashed by the pandemic. In hindsight, it worked. But also in hindsight, the medicine ( fiscal spending and QE) was probably too much and lasted too long. ''
`` I do not envy the Fed for what it must do next: The stronger the recovery, the higher the rates that follow ( I believe that this could be significantly higher than the markets expect) and the stronger the quantitative tightening ( QT). If the Fed gets it just right, we can have years of growth, and inflation will eventually start to recede. In any event, this process will cause lots of consternation and very volatile markets. The Fed should not worry about volatile markets unless they affect the actual economy. A strong economy trumps market volatility. ''
`` One thing the Fed should do, and seems to have done, is to exempt themselves — give themselves ultimate flexibility — from the pattern of raising rates by only 25 basis points and doing so on a regular schedule. And while they may announce how they intend to reduce the Fed balance sheet, they should be free to change this plan on a moment's notice in order to deal with actual events in the economy and the markets. A Fed that reacts strongly to data and events in real time will ultimately create more confidence. In any case, rates will need to go up substantially. The Fed has a hard job to do so let's all wish them the best. ''
`` This year, we announced that the expenses related to investments would increase from $ 11.5 billion to $ 15 billion. I am going to try to describe the 'incremental investments ' of $ 3.5 billion, though I can't review them all ( and for competitive reasons I wouldn't). But we hope a few examples will give you comfort in our decision-making process.
Some investments have a fairly predictable time to cash flow positive and a good and predictable return on investment ( ROI) however you measure it. These investments include branches and bankers, around the world, across all our businesses. They also include certain marketing expenses, which have a known and quantifiable return. This category combined will add $ 1 billion to our expenses in 2022.
`` Over the last 18 months, we spent nearly $ 5 billion on acquisitions, which will increase 'incremental investment ' expenses by approximately $ 700 million in 2022. We expect most of these acquisitions to produce positive returns and strong earnings within a few years, fully justifying their cost. In a few cases, these acquisitions earn money — plus, we believe, help stave off erosion in other parts of our business. ''
`` Our international consumer expansion is an investment of a different nature. We believe the digital world gives us an opportunity to build a consumer bank outside the United States that, over time, can become very competitive — an option that does not exist in the physical world. We start with several advantages that we believe will get stronger over time.... We have the talent and know-how to deliver these through cutting-edge technology, allowing us to harness the full range of these capabilities from all our businesses. We can apply what we have learned in our leading U.S. franchise and vice versa. We may be wrong on this one, but I like our hand. ''
`` Despite the pandemic and talent retention challenges, we continue to boost our representation among women and people of color. … More women were promoted to the position of managing director in 2021 than ever before; similarly, a record number of women were promoted to executive director. By year's end, based on employees that self-identified, women represented 49% of the firm's total workforce. Overall Hispanic representation was 20%, Asian representation grew to 17% and Black representation increased to 14%. '' | business |
The 30 Funniest Twitter Reactions to the 2022 Grammy Awards | Every product on this page was chosen by a Harper's BAZAAR editor. We may earn commission on some of the items you choose to buy.
`` When I tell you I screamed at tae and olivia rodrigo. ''
The Grammys were officially back and bigger than ever—and Twitter had a lot to say about it.
After the COVID-19 pandemic forced last year's affair to take on a hybrid virtual ceremony, this year's event returned to its former full-scale glory: The red carpet was rolled out, golden gramophones were awarded, and Twitter kept the commentary going.
For the first time, the Grammys were held at the MGM Grand Garden Arena in Las Vegas, rather than the Crypto.com Arena ( once known as the Staples Center) in Los Angeles. And The Daily Show's Trevor Noah returned for a second time to host the annual awards show. `` It's been a long time coming, and it has been delayed, but we are officially here, '' Noah said in his opening monologue. `` Better late than never, right? ''
Ahead, some of the best tweets of the night.
They shading Will Smith at the # GRAMMYs 💀💀😆 pic.twitter.com/GsPzoNRiDO
Will Smith slap jokes counter: 3 # GRAMMYs pic.twitter.com/wMvjEHqJ23
lowkey want another will smith-chris rock type of mess in the # GRAMMYs this year... pic.twitter.com/xcEhgzniTU
tonight is olivia rodrigo’ s night ✨ # GRAMMYS pic.twitter.com/548gL96SPE
someone tell little liv that her dream came true pic.twitter.com/8FgcOIrsT9
This is why she won the Grammyhttps: //t.co/1OYN3xeVYP
EXACTLY YES YES BTS MAIN ACT BIGGEST PERFORMERS SMOOTH LIKE BUTTER FUCKERS pic.twitter.com/FKCuNGet2p
`` Namjoon doesn't have his drivers license '' # GRAMMYs pic.twitter.com/6u3CMTtcha
HER is a better woman than me sorry I would have blacked out and shoved Olivia out of her seat like musical chairs pic.twitter.com/9paAMZvxZk
When i tell you i screamed at tae and olivia rodrigo # PassTheButter pic.twitter.com/GpTormKQHK
WHAT THE FUCK V AND OLIVIA # GRAMMYs pic.twitter.com/W1vJJBw14c
Olivia with Kim Taehyung excuse me???? BTS BTS BTS pic.twitter.com/C8eo4kpexe
WHAT JUST HAPPENED? everywhere I go, I keep seeing this olivia and kim taehyung scene and I -- 😭 # GRAMMYs pic.twitter.com/fCZyp44bWu
TAE AND OLIVIA?! WHAT IS GOING ON pic.twitter.com/qeAfY1jnJT
ME WATCHING TAE AND OLIVIA hahah # GRAMMYs pic.twitter.com/IJdEjpvCLY
whatever happened to “ hello? ” “ How are you? ” “ My name is? ” https: //t.co/bYRa0td95E
Okay @ LilNasX with the Dangerously in Love Album cover moment pic.twitter.com/5VdVR62T2N
want to be locked in a room with them in which there are no others https: //t.co/W5VjlMU15A
lost all my grammies so far. let’ s celebrate that! pic.twitter.com/Hq2n86Gy1e
Sza is currently in crutches after carrying RnB on her back with 0 # GRAMMYs pic.twitter.com/wgU2X1fcGs
not a damn thing she just don’ t wan na perform https: //t.co/AIL0CI7tL9
A miracle happens on stage and you’ re calling her a liar https: //t.co/k727Q1Wmkj
WHO ARRANGED THAT SONDHEIM MEDLEY? IT WAS SPECTACULAR. # GRAMMYs ( special shout out to @ CynthiaErivo and @ leslieodomjr) pic.twitter.com/ciouDFiP0Z | general |
BTS Gives a Heist-Themed Performance of `` Butter '' at the 2022 Grammys | Every product on this page was chosen by a Harper's BAZAAR editor. We may earn commission on some of the items you choose to buy.
The BTS members went all out for their first full in-person perfomance.
Grammy viewers just got the full BTS experience.
The seven-member k-pop group gave their first full Grammys performance, with a surprising museum heist staging of their Billboard-topping single `` Butter. '' Jin began the performance, hacking into the switchboard of their museum/stage and Jungkook descended down from the ceiling. Other members, like V sharing a quick chat with Olivia Rodrigo, were stationed in the audience.
The stage version of `` Butter '' included a new dance break, complete with members dodging lasers and an impressive coat trick. They then finished the performance with the original choreography, backed up by dancers from The Lab Studios.
The Korean mega group received their second Grammy nomination this year for `` Butter, '' after making history as the first k-pop band ever to be nominated—for their pop-disco hit `` Dynamite '' —last year. This year, their category—Best Pop Duo/Group Performance—will be presented on the main broadcast.
During an E! red carpet interview, leader RM spoke about the significance of the nominations.
`` It's an award voted on by the peers in the music industry, so that means so much, '' he said. `` These two years were so exhausting and devastating and if we got any Grammys it would all pay off. ''
The past week has been emotional for BTS fans, aka ARMY, after member Jungkook tested positive for COVID-19 upon landing in Las Vegas last weekend. Luckily HYBE, the South Korean entertainment company behind the band, announced yesterday that the vocalist made a full recovery after self-quarantine and was approved to participate in the Grammys after testing negative.
Rapper J-Hope, who tested positive earlier this month and completed his self-quarantine in Seoul last week, also joined the members in Vegas yesterday. | general |
Lady Gaga Dazzles with `` Love for Sale '' Performance at the Grammys | Every product on this page was chosen by a Harper's BAZAAR editor. We may earn commission on some of the items you choose to buy.
The singer also showed off her smooth jazz moves.
Lady Gaga dazzled the Grammys audience tonight with her melodic renditions of `` Love for Sale '' and `` Do I Love You, '' from her Love for Sale album with Tony Bennett.
After Bennett introduced her via a video message featured on the big screen at the ceremony, the singer, in a glamorous Tiffany blue gown by Elie Saab, showed her smooth jazz moves and sang, accompanied only by a piano.
`` I feel so blessed to be a part of this wonderful community of musicians, and I want the whole world to know that we love making you smile, '' Gaga said after her performance of `` Love for Sale. ''
`` So if you're wondering how we feel, do I love you? Oh, boy, do I, '' the singer said before sliding into her performance of `` Do I Love You. ''
`` I love you, Tony, we miss you, '' she said at the end.
The singer will likely take home some Grammy gold tonight. Her jazz standards album recorded with Bennett is up for Album of the Year, with the lead single, `` I Get a Kick Out of You, '' also nominated for Record of the Year.
Prior to her grand stage moment, Gaga walked the red carpet at the MGM Grand Garden Arena in Las Vegas in a black custom gown by Giorgio Armani Privé.
Gaga's return to the Grammys stage comes a week after she capped off a jam-packed awards season for her film House of Gucci. The star ended last Sunday's eventful Academy Awards ceremony by presenting the award for Best Picture alongside movie musical legend Liza Minnelli. To the event, the multi-hyphenate wore a sequined spin on a classic tuxedo, complete with diamond jewelry, black pumps, and a bow tie.
This summer, the 12-time Grammy winner will embark on her Chromatica Ball tour, which was previously scheduled for March 2020, but was postponed due to the COVID-19 pandemic. The star will kick off the tour in Europe in July and continue with her North American shows starting in August. | general |
Two years on: Progress and country uptake of the ECDI2030 | Thriving in the first few years of life is the right of every child. It is also the foundation of future health, well-being and productivity, according to scientific evidence from multiple disciplines.
Growing recognition of the vital importance of early childhood development ( ECD) is attested by its inclusion in the 2015 Sustainable Development Goals ( SDGs). SDG target 4.2 seeks to “ ensure that, by 2030, all girls and boys have access to quality early childhood development, care and pre-primary education, so that they are well prepared for primary education. ” Giving all children a good start in life is crucial for achieving other global goals as well, including eradicating hunger and poverty, living healthier lives, reducing inequality, fostering economic growth and building peaceful societies.
One indicator for target 4.2 is the “ proportion of children 24 to 59 months of age who are developmentally on track in health, learning and psychosocial well-being, ” disaggregated by sex. But while the target itself is straightforward, finding a way to measure it was not. Doing so involved a rigorous, five-year long methodological process, spearheaded by UNICEF.
Measuring early child development is extraordinarily complex since the progress of young children is multidimensional – with physical, cognitive, emotional, behavioural and other components. Nor do children develop in lockstep. Moreover, any measure that was agreed upon had to be short and simple, since it was mainly intended for use in multi-topic household surveys in countries already overwhelmed by the new monitoring requirements established by the SDGs. What’ s more, the measure had to be culturally appropriate and applicable for capturing child development worldwide.
Traditional approaches to measuring early childhood development have been based on individual screening and/or diagnostic tests administered by highly trained professionals. These are inappropriate for the type of large-scale population monitoring needed for the SDGs. In contrast, the tool that was eventually developed – the Early Childhood Development Index 2030, or ECDI2030 – consists of 20 questions a child’ s mother or primary caregiver can answer in about three minutes. The questionnaire replaces a 10-question module that had been included since 2009 in the standard Under-5 Questionnaire in the UNICEF-supported Multiple Indicator Cluster Surveys ( MICS).
The ECDI2030 covers the three domains of early childhood development included in the SDG indicator: learning, psychosocial well-being and health. The goal was to capture the essence of these domains in as few questions as possible ( see figure below), in order to make the final measure simple and cost-efficient for countries to use. Questions in the psychosocial well-being domain, for example, focus on a child’ s emotional and social skills as well as their tendency – or not – to internalize or externalize their emotions.
To ensure that the questions could be readily understood and were relevant and valid across local contexts, cognitive and methodological testing was carried out in eight countries. The entire process involved extensive consultations with international experts, partner agencies and national statistical authorities and was overseen by the Inter-Agency and Expert Group on ECD Measurement. Support along the way was provided by a technical advisory group of academics and researchers as well as practitioners with expertise in assessing child development around the world.
The ECDI2030 is accompanied by a complete package of implementation tools, translated into multiple languages. UNICEF has also produced a dedicated technical manual and several academic articles documenting the methodological process behind the development and validation of the measure.
In 2019, the ECDI2030 was recognized as the measure for monitoring and reporting on SDG 4.2.1. It took another two years, amid the COVID-19 pandemic, for three countries – Eswatini, Nigeria and Viet Nam – to integrate the module into national surveys as part of the sixth round of MICS ( MICS6) and collect the relevant data; up to 15 other countries are in various stages of MICS6 implementation. Beginning in 2023, the ECDI2030 module will become a standard part of MICS7. It has also been included in several Demographic and Health Surveys planned for this year and in other national data collection efforts, including in Indonesia, Mexico and Sri Lanka. In response to COVID-19, a pilot study supported by the UNICEF country office in Nepal demonstrated the viability of administering the ECDI2030 module by phone.
To encourage uptake of the module, efforts have also focused on capacity-building. UNICEF is partnering with the United Nations Statistical Institute of Asia and the Pacific to conduct a virtual training workshop on the ECDI2030 in May 2022 for national statistical offices in the region. UNICEF is also organizing a virtual training workshop on collecting data for ECD-related indicators, including the ECDI2030, through household surveys.
The methodological intricacy of developing the ECDI2030 has been an exciting advancement for the field of ECD measurement at the population level. Still, it is only a first step. More important is what countries do with it. The ECDI2030 will enable countries to gather the data needed to monitor progress towards the SDG target. At the same time, these data can be used to develop evidence-informed policies and programmes that can make a real difference in the lives of children.
One of the remaining challenges is enabling countries to track developmental progress in children aged 0 through 6. This will require stronger alignment across existing instruments. Accordingly, UNICEF, the World Health Organization and the World Bank have come together to explore ways to link various measurement efforts for assessing child development up to 7 years of age.
Meanwhile, UNICEF continues to support countries in analysing collected data, interpreting the results, and disseminating findings to a broad audience so they can be strategically used in advocacy and programming. Such data are critical to devising effective policies, identifying gaps in programmes and services for young children, and scaling up successful interventions to accelerate progress.
Learn more about the ECDI2030 and access implementation tools in seven languages. | general |
U.S. oil prices settle back above $ 100 as Europe weighs additional Russia sanctions | Oil futures settled higher on Monday, with U.S. prices back above the $ 100 mark after posting the biggest weekly drop in two years, as European leaders called for additional sanctions against Moscow following images over the weekend showing evidence of Russian atrocities in Ukraine.
Price action
West Texas Intermediate crude for May delivery
CL.1,
+1.95%
CL00,
+1.95%
CLK22,
+1.95%
rose $ 4.01, or 4%, to settle at $ 103.28 a barrel on the New York Mercantile Exchange after settling Friday at $ 99.27, the lowest since March 16.
June Brent crude
BRN00,
-0.37%
BRNM22,
-0.37%
,
the global benchmark, rose $ 3.14, or 3%, at $ 107.53 a barrel on ICE Futures Europe. WTI, the U.S. benchmark, fell 12.8% last week, while Brent dropped 11.1%, the biggest weekly percentage declines for both since late April 2020.
May gasoline
RBK22,
+2.43%
tacked on 1.4% to $ 3.198 a gallon and May heating oil
HOK22,
+1.60%
added 3.6% to $ 3.546 a gallon.
May natural gas
NGK22,
-0.57%
settled at $ 5.712 per million British thermal units, down 0.1%.
Market drivers
The weekend saw grim headlines and images emerge out of Ukraine as Russian forces pulled back from positions near Ukraine’ s capital, Kyiv. So far,
the bodies of 410 civilians have been found in towns near the capital
that were recently retaken from Russian forces, said Ukraine’ s prosecutor-general, Iryna Venediktova.
“ As long as the geopolitical uncertainty linked to the Russia-Ukraine war persists, global oil markets will maintain a fear-bid, ” Tyler Richey, co-editor at Sevens Report Research, told MarketWatch.
Images of bodies, many showing signs of torture, in the city of Bucha prompted several European leaders to call for tougher sanctions against Moscow.
“ The EU ( European Union) is still unlikely to ban Russian oil and gas imports because it would not be possible to find an alternative supply of the latter in particular at short notice, meaning such a step would have serious economic consequences, ” said Carsten Fritsch, commodity analyst at Commerzbank, in a note.
“ Nonetheless, this topic is likely to move further into focus again after having seemingly taken more of a back seat of late, while the uncertainty surrounding the payment modalities for purchases of Russian gas has also abated, ” he said.
The oil market was volatile last week, slumping as the U.S. announced the release of 1 million barrels a day of crude for the next six months from its Strategic Petroleum Reserve, while the International Energy Agency on Friday said they would release additional barrels.
Read:
What Biden’ s historic decision to release oil reserves means for the market
In other news, Saudi Aramco announced Monday that it raised its May oil prices for customers in all regions, with prices for the four types of oil it sells to the U.S. up by $ 2.20 a barrel from April. That also helped to bolster oil prices Monday, said Sevens Report Research’ s Richey.
Still, “ there are some technical cracks emerging in the uptrend, ” suggesting that WTI is potentially poised for a corrective pullback into the low to mid $ 90’ s, Richey said. “ That would very likely occur on any positive developments in ceasefire negotiations between Russia and Ukraine. ”
Meanwhile, rising COVID-19 cases in China has raised expectations for a decline in energy demand. The country last month locked down Shanghai, its largest city and financial capital, as part of its zero-COVID policy.
Investors were also weighing the announcement late Friday of
a two-month truce
in Yemen between a Saudi-affiliated coalition and Iran-backed Houthi rebels. Crude-oil volatility had been amplified in recent weeks amid Houthi drone attacks on Saudi oil facilities. | business |
Democratic, Republican bargainers reach $ 10B COVID-19 treatment agreement in Senate | Senate bargainers reached agreement Monday on a slimmed-down $ 10 billion package for countering COVID-19 with treatments, vaccines and other steps, the top Democratic and Republican negotiators said, but ended up dropping all funding to help nations abroad combat the pandemic.
The compromise drew quick support from
President Joe Biden,
who initially pushed for a $ 22.5 billion package. In a setback, he ended up settling for much less despite administration warnings that
the government was running out of money
to keep pace with the disease’ s continued — though diminished — spread in the U.S.
“ Every dollar we requested is essential and we will continue to work with Congress to get all of the funding we need, ” said White House press secretary Jen Psaki. “ But time is of the essence. We urge Congress to move promptly on this $ 10 billion package because it can begin to fund the most immediate needs. ”
Biden and Senate Majority Leader Chuck Schumer, D-N.Y., his party’ s lead bargainer, abandoned Biden’ s request to include $ 5 billion to help countries — especially poorer ones — where the disease is still running rampant.
The inability of Biden and top Democrats to protect the additional spending they wanted came after the two parties gridlocked over GOP demands to pay for it by pulling back unspent aid from
earlier pandemic measures
. It also reflected the diminished political force that battling COVID-19 has this election year, two years into a pandemic that began with bipartisan support for throwing trillions of dollars at it.
Sen. Mitt Romney of Utah, the lead GOP bargainer, hailed the accord as one that would address “ urgent COVID needs. ” He also trumpeted the measure’ s savings, which he said meant it “ will not cost the American people a single additional dollar. ”
Still uncertain Monday was whether objections by some Republicans might prevent the Senate from considering the bill this week, as Biden wants, before Congress begins a two-week spring recess. It was also not yet certain there would be the minimum 10 GOP votes needed for passage in the 50-50 chamber.
Its fate was also not guaranteed in the House, where House Speaker Nancy Pelosi, D-Calif., and many liberals have criticized the ejection of global assistance. But party leaders there signaled they were ready to compromise.
House Majority Leader Steny Hoyer, D-Md., said, “ That’ s all the Senate can do right now, which I regret deeply, then I think we need to pass that ” as fast as possible. A senior House Democratic aide, speaking on condition of anonymity to describe internal thinking, said it would be best to take what was achievable and fight for more later.
Schumer said the agreement would provide “ the tools we need ” to help the country recover from the economic and public health blows that COVID-19 has inflicted. But he said while the $ 10 billion “ is absolutely necessary, it is well short of what is truly needed to keep up safe ” over time.
He said members of both parties want to craft a second spending measure this spring that could include funds to battle COVID-19 and hunger overseas and more assistance for Ukraine as it continues battling the Russian invasion. The fate of such a measure is uncertain.
Romney also suggested an openness to considering future money. “ While this agreement does not include funding for the U.S. global vaccination program, I am willing to explore a fiscally responsible solution to support global efforts in the weeks ahead, ” he said.
The agreement comes with BA.2, the new omicron variant, expected to spark a fresh increase in U.S. cases. Around 980,000 Americans and over 6 million people worldwide have died from COVID-19.
At least half the agreement’ s $ 10 billion would be used to research and produce therapeutics to treat the disease, according to fact sheets from Schumer and Romney.
The money would also be used to buy vaccines and tests. At least $ 750 million would be used to research new COVID-19 variants and to expand vaccine production, the descriptions said.
Administration officials have said the government has run out of money to finance COVID-19 testing and treatments for people without insurance. They’ ve also said funds are running low for boosters, vaccines focused on specific variants, free monoclonal antibody treatments and care for people with immune system weaknesses.
The deal is also a reduction from a $ 15 billion version that both parties’ leaders negotiated last month. Pelosi abandoned that plan after Democratic lawmakers rejected proposed cuts in state pandemic aid to help pay for the package.
Democrats from both chambers complained about the eliminated global spending.
Rep. Pramila Jayapal, D-Wash., leader of the House Progressive Caucus, said it is “ a big problem ” to erase the international assistance and “ not spend money on making sure this virus is contained around the world. ”
Sen. Chris Coons, D-Del., a leading foreign policy voice, said he would back the bill but called it a “ grave mistake ” to not help other countries’ efforts. He called it “ fiscally foolish ” to not send tens of millions of unused U.S. vaccines abroad to the 2.8 billion unvaccinated people worldwide.
The measure is fully paid for by pulling back unspent funds from previous pandemic relief bills that have been enacted, bargainers said.
Romney’ s fact sheet says that includes $ 2.3 billion from a fund protecting aviation manufacturing jobs; $ 1.9 billion from money for helping entertainment venues shuttered by the pandemic; another $ 1.9 billion from a program that helps states extend credit to small businesses; and $ 1.6 billion from agriculture assistance programs. | business |
‘ Like a horror story’ – Bucha residents pay tribute to city brought to ruin | A woman walks amid destroyed Russian tanks in Bucha. Picture: AP Photo/Rodrigo Abd
People from Bucha have told of the “ happy life, different plans and dreams for the future ” they have lost as a result of the consistent attacks on the city.
Bodies with bound hands, close-range gunshot wounds and signs of torture lay scattered across the city, which lies on the outskirts of Kyiv, after Russian soldiers withdrew from the area.
Nadia Melnychuk, 27, owns a cottage in Bucha with her husband, Roman, and said knowing neighbours have been killed in their “ little, beautiful city ” is “ like a horror story ”.
“ We didn’ t want to see this life, we didn’ t want to have war, ” Ms Melnychuk, a PR manager, told the PA news agency.
“ In February and January we had a simple, happy life there… We had a happy life, different plans and dreams for our future, and after that we lost everything we had.
“ We couldn’ t even know – our house, is it still here? We have no information about it. ”
Ms Melnychuk and her husband moved from Kyiv to Bucha during one of Ukraine’ s Covid lockdowns last year.
When Hostomel Airport was struck by Russian air forces just outside the city on the first day of the invasion, they could see it from the windows of their cottage.
They left Bucha for western Ukraine as soon as they could.
“ It’ s like a horror story, ” Ms Melnychuk said.
“ We know that our neighbours, who live not far from our cottage house, some of them are killed.
“ We couldn’ t even come into contact with our relatives who stayed in Bucha for the first two weeks because they were under their houses.
“ They tried to be in a safe place because there were rockets everywhere and soldiers killed everyone they see on the streets. ”
She confirmed her relatives, including her mother-in-law, have now left the city, but described what some of them had seen in Bucha.
“ There were stories from our relatives who told us that they tried to go to houses of people, and if someone didn’ t open their door to the Russian soldiers, didn’ t give them food or something – because Ukrainians don’ t want to be in contact with them, they are occupiers – they killed Ukrainians, ” she said. | general |
Optimizing Supply Chain & Sourcing in Times of Disruption | Traditional supply chain systems were focused on functional efficiency, often at the expense of agility. Leveraging the latest digital enablers, new forms of data, and AI, Coupa’ s Supply Chain offering, powered…
As organizations strive to reduce costs while increasing speed, the process of procuring materials, making products, and moving them where they need to be is more complex than ever.
In addition to material shortages, labor challenges, and pandemic-related limitations, suppliers and manufacturers are now facing rising costs and bottlenecks in transportation.
In this disruptive environment, organizations must drive collaboration between sourcing and supply chains to align decision-making and secure the transportation capacity they need.
By increasing visibility and sharing information through collaborative technologies, organizations can now optimize supply chain design and sourcing with the resilience they need to face disruptions.
Supply chain transportation is becoming increasingly complex, with rising costs and risks along the way. While growth in e-commerce has amplified logistics capacity challenges in the past decade, the pandemic has also led to whirlwinds in demand and capacity. Lockdowns, quarantines, and social distancing hampered production in 2020 while the emergence of the Delta variant extended the pandemic in 2021.
In addition, events like the Suez Canal blockage and the traffic jams at Los Angeles and Long Beach ports have added to the disruption. As a result, organizations have experienced shortages on a level that few ever have.
Compounding the problem is the fact that costs are rising. Shipping rates for a 40-foot container from China to the U.S. east coast reached a record high of $ 22,000 in September 2021, up nearly 500% from nearly $ 4,600 a year earlier, according to the Freightos Baltic Index ( 1). Hong Kong to U.S. air freight rates also reached a high of $ 9.70 per kilo in September 2021, up 85% from the previous year, according to the Baltic Exchange Air Freight Index ( 2). Here in the United States, driver shortages are impeding coast-to-coast deliveries and increasing load-to-truck ratios.
For many companies, these challenges are compounded by organizational silos and limited collaboration between supply chain and sourcing. This limits responsiveness and savings potential because while business units may find their savings, they fail to see how their efforts impact the broader supply chain.
In this current state of constant disruption, organizations need a greater focus on resiliency and agility. We have discovered time and time again that procurement and supply chain are smarter together. By bridging the gap, they can optimize both supply chain design and sourcing to drive greater business value and better equip themselves to manage future disruptions.
This collaboration is especially critical in transportation, where optimization requires strategic input from other business areas, including logistics sourcing. Organizations need to look beyond simply finding the lowest cost solution to ensure suppliers meet critical capacity needs, service levels, and other considerations. These things all need to factor into a supplier's total cost perspective, and ultimately, into the purview of procurement and sourcing.
Aligning decision making and driving collaboration between these two functions can help shorten the time between identifying and securing transportation capacity needs. It can also optimize the transportation routes based on current market information and mitigate risk when accommodating shifting demand patterns. For example, a medical device company overcame COVID disruptions by quickly pivoting to change modes of transportation and unlocking tens of millions of dollars in savings opportunities.
However, one of the greatest impediments to this collaboration is fragmented systems. Many organizations still rely on email, spreadsheets, and phones, which slow down the process and time from decision to execution. This takes longer to identify transportation needs, making it challenging to work together on adjusting transportation modes and mitigating the risk to the fullest ability.
To enable this collaboration, organizations need technologies that bring together strategic inputs and requirements from procurement and supply chains.
Coupa helps organizations make their supply chains more adaptable and resilient by unifying previously disparate processes across these two business units. Coupa’ s Business Spend Management ( BSM) platform offers everything organizations need to optimize spending in one place in a scalable, easy-to-use, cloud-native platform. This critical link, known as our Supply Chain Design-to-Source suite synergy, helps bridge our Supply Chain Design & Planning and Sourcing Optimization capabilities to optimize transportation lanes.
With this solution, users can optimize the network and capacity model, run sourcing events for identified transportation lanes, and leverage the most current market information to further optimize networks. Creating more holistic supply chain models and seamlessly executing sourcing events allows organizations to improve speed to market, asset utilization, and business value. It offers this while also supporting the resilience and agility required to forge market leadership today and in future disruptions.
In this era of disruption, the only certainty is uncertainty. By fostering collaboration between supply chain and procurement, organizations will be better prepared to respond to whatever is on the horizon.
1 `` Freightos Baltic Index ( FBX): Global Container Freight Index, '' Freightos Data.
2 `` Baltic Air Freight Indices ( BAI): powered by TAC data, '' Baltic Exchange.
Digital Supply Chain’ s Evolving Role in the Enterprise Agenda The Hackett Group 2020 Key Issues Study findings confirm that the mantra of “ doing more with less ” is still prevalent, but the top concern of supply chain leadership is that their organizations are in fact overcommitted, to AI analytics to enable a more agile supply chain. Download Now!
Risk, Resiliency, and Supply Chain Modeling This paper first examines why existing supply chain management practices do not naturally develop resilient supply chains and why some of the existing supply chain processes are not suitable for addressing such risks and required responses. Download Now!
Continuous Design Outsmarts Disruption: A Blueprint for Supply Chain Resiliency In this ebook, we discuss how continuous design can reduce risk, improve resilience, and turn supply chain challenges into a competitive advantage. Download Now! | general |
PwC: Ireland faces 'wave of business failures ' | The winding down of Covid business supports will likely lead to a rise in insolvencies in Ireland. Picture: iStock
Irish businesses face `` a wave '' of insolvencies starting this year after a record low level of failures during the Covid-19 crisis, according to PwC.
Business failure rates were running at 15 per 10,000 firms in the last 12 months — the lowest for 17 years — but have increased in the first three months this year.
The winding down of Covid business supports will likely lead to a rise in insolvencies in Ireland, as has happened in Britain, according to PwC.
“ Most business owners are very aware that the current economic environment is very fluid, given the war in Ukraine, and businesses are facing some strong headwinds in the form of geopolitical uncertainty, higher energy costs and price inflation, continued supply chain issues as well as upward pressure on interest rates, ” said Ken Tyrrell, business recovery partner at PwC Ireland. | general |
Grammys 2022 Winners: See the Full List Here | The 64th Grammy Awards had a total of 86 categories, and with the Grammys 2022 winners list officially announced, there are now 88 new winners — there were two ties this year! Check out the list below to see if your favorite artist took home a coveted trophy.
Aired on Sunday, April 3, this year's show took place at the MGM Grand Garden Arena in Las Vegas. Usually held in January in Los Angeles, the ceremony was postponed and rescheduled due to the COVID-19 Omicron surge this past winter.
The 2022 Grammys were hosted by comedian and The Daily Show host Trevor Noah, who previously hosted the 2021 Grammy Awards. “ I said, ‘ Let me think about it,’ and then I was like, ‘ Why would I not want to do the Grammys?’ ” Noah said in an interview with CBS ' Gayle King. “ First of all, it’ s a front row ticket to the best music concert of all time. I don’ t care who you are, you love music. ”
Since the majority of the Grammy Awards were presented during the official Grammy Premiere Ceremony earlier in the day on April 3, the main event fit exactly into Noah's description: a big ol ' music concert.
Audiences were treated to performances from the likes of Silk Sonic, Lil Nas X and Jack Harlow, Lady Gaga, and Justin Bieber with Giveon and Daniel Caesar. Olivia Rodrigo made her Grammy stage debut, performing her hit single “ Drivers License ” on a purple-lit set, complete with vintage car and suburban cul-de-sac. BTS had one of the most buzz-worthy performances of the night, with their stunning performance of their global mega-hit “ Butter '' — with Jungkook literally dropping in from the ceiling like James Bond. Talk about a show-stopper.
Some of the biggest wins of the night included funk duo Silk Sonic, comprised of Bruno Mars and Anderson.Paak, who took home all four awards they were nominated for, including Record of the Year and Song of the Year for their single “ Leave the Door Open. ” First-time nominee Olivia Rodrigo also won three prizes: Best New Artist, Best Pop Solo Performance, and Best Pop Vocal Album for her debut project Sour.
The competition was fierce for Best Pop Duo/Group Performance, featuring standout nominee BTS, but the award ultimately went to Doja Cat and SZA for their chart-topper “ Kiss Me More, ” making their collaboration only the second all-female collab to ever win in the category.
Expected Grammy frontrunners Billie Eilish and FINNEAS and Lil Nas X also had incredible performances, yet took home no prizes. But it was all love from FINNEAS, who tweeted when the big night was over: “ We love everyone who won tonight!! I don't wan na see anyone talking any trash at ALL! Nothing but love!! Talented musicians won tonight!! We were lucky to be nominated!! ”
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An assertive, practical, and substantive agenda to catalyse meaningful change - The Lancet Global Health | The Lancet Global Health Commission on financing primary health care1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; ( published online April 4.) https: //doi.org/10.1016/S2214-109X ( 22) 00005-5Google Scholar combines a shared vision with practical guidance on how to align health financing with overall reform strategies that place primary care service delivery at the core. The Commission reinforces key messages that WHO has put forward on health financing reforms to enable progress towards universal health coverage ( UHC). It then extends these by application to primary care as a critical service delivery element for the progressive realisation of UHC. WHO's guidance on health financing is crystallised into a framework for regular country assessment to inform policy dialogue.2Jowett M Kutzin J Kwon S Hsu J Sallaku J Salano JG Assessing country health financing systems: the health financing progress matrix. World Health Organization, Geneva2020Google Scholar The alignment of the Commission with this guidance is clear, as reflected in the table. While the decision to limit the operational definition of primary health care ( PHC) to service delivery platforms was made for the purposes of the Commission, certain key financing issues merit further attention. We point to these towards the end of this Comment.TableAlignment of the Lancet Global Health Commission recommendations with WHO guidance on health financingWHO progress matrix desirable attributeCommission recommendationHealth expenditure is based predominantly on public funding sourcesPublic resources should provide the core of PHC funding, with minimal reliance on direct payments when services are accessedBenefit design includes explicit limits on user charges and protects access for vulnerable groupsPublic resources should provide the core of PHC funding, with minimal reliance on direct payments when services are accessedPooling structure and mechanisms across the health system enhances the potential to redistribute available prepaid fundsReduce fragmentation, thereby creating an enabling environment for more equitable cross-subsidies between healthy and ill as well as rich and poor, more efficient integration between levels of care, and better coordination with services in ( often donor-funded) disease or intervention-specific programmesHealth system and financing functions are integrated or coordinated across schemes and programmesReduce fragmentation, thereby creating an enabling environment for more equitable cross-subsidies between healthy and ill as well as rich and poor, more efficient integration between levels of care, and better coordination with services in ( often donor-funded) disease or intervention-specific programmesResource allocation to providers reflects a combination of population health needs and provider performancePayment methods should assign resources based on people's health needs and align incentives with people-centred servicesPurchasing arrangements are tailored in support of service delivery objectivesPayment methods should assign resources based on people's health needs and align incentives with people-centred servicesA set of priority health service benefits within a unified framework is implemented for the entire populationPooled funds should cover PHC and enable all people to receive it free at the point of useHealth budget formulation and structure support flexible spending and are aligned with sector prioritiesPublic financial management systems must be flexible and straightforward, enabling managers to respond to the changing needs of patients, families, and communitiesProviders can directly receive revenues, flexibly manage them, and report on spending and outputsFunds flow to and are managed by frontline providers ( autonomy) PHC=primary health care. Open table in a new tab
From a health financing perspective, perhaps the most far-reaching and potentially influential recommendations in the Commission are ( a) to move towards a coherent mixed-provider payment model for PHC with capitation at the core, and ( b) to universalise PHC coverage while eliminating or greatly reducing out-of-pocket payments for these services. We agree; here we identify some key issues of policy and implementation alignment that are implied by these directions.
Universality requires that the funding base, particularly but not only in low-income and middle-income countries ( LMICs), would rely predominantly on general government budget revenues, regardless of whether they flow directly to providers or via a service purchasing agency such as a health insurance fund. For any payment system paid from government budget revenues to be effective, budget formulation, and execution—the fundamentals of public financial management—will need to function sufficiently well to enable providers to receive a steady, predictable flow of funds3Piatti-Funfkirchen M Barroy H Pivodic F Margini F Budget execution in health: concepts, trends and policy issues. World Bank, Washington, DC2021Google Scholar with the ability to manage these flexibly.4O'Dougherty S Mtei G Kutzin J Barroy H Piatti-Funfkirchen M Direct facility financing: concept and role for UHC. World Health Organization, Geneva2022Google Scholar This can be facilitated with the design of a programme-based budget that is defined in a way ( eg, as access to PHC services) that aligns with the capitation strategy and shifts control and monitoring from inputs to predefined performance indicators that are progressively refined over time.
In reality, a country's starting point for reorienting provider payment to a more coherent set of incentives for “ people-centred care ” is more complex than the extremes of either line-item budgets or unmanaged fee-for-service, given the fragmentation of revenues flowing from different schemes and programmes that exists in most countries. Thus, a diagnostic of initial payment arrangements5Mathauer I Dkhimi F Analytical guide to assess a mixed provider payment system. World Health Organization, Geneva2018https: //www.who.int/publications/i/item/978-92-4-151533-7Date accessed: March 25, 2022Google Scholar will be essential to create a realistic transition process. As the people-centred payment model of capitation becomes more sophisticated, it should move beyond one level of care and be designed in a way to explicitly encourage provision of services and tasks at lower-level facilities and provider types that are increasingly close to the population they serve. But financial incentives alone are not enough; from early in the reform process, it will be essential to identify service delivery strategies tailored to local needs, including settings challenged by inadequate levels or mix of health workforce, which address underlying performance issues, and then to align the specifics of purchasing with these strategies.
Universalising coverage for PHC services means, in effect, that entitlement to services would have to be entirely or predominantly non-contributory in nature, or done so de facto by relying on general revenues to fund coverage for the uninsured in countries relying mainly on social health insurance. This mechanism aligns with a growing consensus6Kutzin J Yip W Cashin C Alternative financing strategies for universal health coverage.in: Scheffler RM Handbook of global health economics and public policy. Vol 1, Ch 5, 267–309 – The Economics of Health and Health Systems. World Scientific Publishing, Singapre2016https: //www.worldscientific.com/doi/abs/10.1142/9789813140493 0005Date accessed: March 25, 2022Google Scholar, 7Yazbeck AS Savedoff WD Hsiao WC et al.The case against labor-tax-financed social health insurance for low- and low-middle-income countries.Health Affairs. 2020; 39: 892-897Google Scholar about the weakness of contributory-based entitlement ( typically in the form of social health insurance) in contexts of limited labour formality.
As noted by the Commission, most out-of-pocket spending in PHC is for medicines. To eliminate or greatly reduce such payments, it is essential that prescribed medicines are made available either without co-payment or with low and explicit limits that are fixed in absolute rather than percentage terms.8Thomson S Cylus J Evetovits T Can people afford to pay for health care? New evidence on financial protection in Europe. WHO Regional Office for Europe, Copenhagen2019Google Scholar This has obvious implications for prioritising generic medicine, management of prescribing patterns, strong price negotiation processes, and where relevant, contracting with private pharmacies.
Universalising PHC combined with the approach of progressing towards a purposively aligned mixed-provider payment system centred on capitation will require, concurrently, taking steps towards a unified or interoperable population ( and eventually health service use) database, regardless of affiliation to specific health programme or coverage schemes. This is perhaps a “ hidden agenda ” for UHC, as unified data systems are a critical input for learning, adaptable ( ie, resilient) health systems, reflected in the strategic pathway shown in figure 11 of the report.
Finally, choosing capitation is a political act, because it requires an explicit, up-front decision on the share or amount of the budget that will be allocated to this purpose. Thus, the Commission's recommendations to have applied political economy analysis9Sparkes SP Bump JB Őzçelik EA Kutzin J Reich MR Political economy analysis for health financing reform.Health Systems Reform. 2019; 5: 183-194Google Scholar as an integral part of policy development is particularly relevant here.
From the perspective of expenditure tracking, interpreting PHC as a service delivery system or platform is appealing because it is measurable. Because PHC is not a category in the System of Health Accounts, estimates have to be constructed based on choices about which expenditure categories to assign to it. A “ global ” measure of PHC is inherently challenging because countries differ in how they organise PHC, and thus no global measure will be equally relevant to all countries. The global measure used by WHO10Eigo N McDonald L Hernandez P Rivas L Dupuy J Xu K Measuring primary health care expenditure under SHA 2011. World Health Organization, Geneva2021Google Scholar was the product of extensive consultation. However, as more countries engage in monitoring PHC spending, and as new service delivery models emerge following the pandemic, ensuring policy relevance and cross-country comparability requires that we periodically revisit the measure; the Commission's recommendations are very helpful for this agenda. As the Commissioners have recognised, what is most important is to improve the quality and increase the frequency with which countries produce their own health accounts. Then, based on how PHC is organised in the country, they can cross-tabulate the “ provider ” and “ function ” classifications to assign expenditures to PHC in a way that is most policy-relevant in the national context.
For those of us who work on health financing, considering primary health care only in terms of service delivery is familiar, comfortable ground. The concept of PHC, however, is broader,11Ghebreyesus TA Strengthening our resolve for primary health care.Bull World Health Organ. 2020; 98 ( 26A): 726Google Scholar and a next generation of work on “ financing for health ” is needed to reflect this, for example by taking on the challenge of multisectoral budgeting12McGuire F Vijayasingham L Vassall A et al.Financing intersectoral action for health: a systematic review of co-financing models.Globalization Health. 2019; 15: 86Google Scholar aimed at addressing cross-cutting public health functions and health determinants emanating from outside as well as inside the health system. As the Commission authors note, we need to adapt our financing levers to population-based essential public health functions across service delivery platforms. In addition, enabling people and communities to take a more proactive role in their health likely requires some rethinking of health financing instruments from a more “ demand-side ” perspective. The Commission highlights the importance of these issues, but country evidence is limited, and there is great scope for further policy development. Similarly, the design of financing instruments to support health in all policies and an “ economy for health ” 13WHO Council on the Economics of Health for AllFinancing Health for All: increase, transform, and redirect. Council Brief No. 2. World Health Organization, Geneva2021https: //www.who.int/publications/m/item/council-brief-no-2Date accessed: March 25, 2022Google Scholar warrant further attention to lay out an actionable agenda going forward.
There is no global blueprint for how to organise financing to support PHC as the means for the progressive realisation of progress towards UHC. But the fact that we do not know everything does not mean that we do not know anything. Some ways of doing things are better than others.14Kutzin J Anything goes on the path to universal health coverage? No.Bull World Health Organ. 2012; 90: 867-868Google Scholar The Commission continues and deepens this more assertive approach to health financing. The Commission starts from the position that stronger PHC is the best ( more equitable, more efficient) approach for the progressive realization of UHC, and then applies what is known about health financing to provide concrete guidance and clear directionality to governments and international agencies. The Commission's specific emphasis on the political economy of PHC-oriented health financing reforms is important to address the question of why, despite all the years that have passed since 1978, these reforms have not gained traction in so many countries. By clearly stating concrete technical approaches that align to PHC and explicitly recognising the inherently political nature of these processes, the Commission will, we hope, catalyse practical approaches that move beyond rhetoric and agenda-setting to actual implementation.
We declare no competing interests.
The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care ( PHC) into sharp focus. PHC is the best platform for providing basic health interventions ( including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open Access | tech |
Public financing for primary health care is the key to universal health coverage and strengthening health security - The Lancet Global Health | The last time global leaders met in person to discuss health issues was at the UN high-level meeting on universal health coverage ( UHC) in New York, NY, USA in September, 2019. At this gathering, heads of government re-committed themselves to the Sustainable Development Goal 3, which aims to ensure that everyone can receive the health services they need without suffering financial hardship.
But in listening to heads of government deliver their speeches, it was striking how many of them said that their strategy to reach UHC was based on giving people better access to expensive hospital services, rather than to primary health-care ( PHC) services. This was a phenomenon I also witnessed when I visited India in 2018, where I was told that one of the primary objectives of their health reforms was to increase hospitalisation rates among poor people.1Brundtland GH India's health reforms: the need for balance.Lancet. 2008; 392: 1174-1175Google Scholar
Speaking as a member of The Elders and as a former WHO Director-General at the high-level meeting, I proposed that a more efficient and equitable route to UHC would be achieved through PHC reforms that were publicly financed. I also used this opportunity to highlight the findings of the first report of the Global Preparedness Monitoring Board,2Global Preparedness Monitoring BoardA world at risk: GPMB 2019 annual report.https: //www.gpmb.org/annual-reports/annual-report-2019Date accessed: March 24, 2022Google Scholar that the world was at great risk from a pandemic of an airborne pathogen due to alarming gaps in global preparedness against health emergencies. This danger was due to a chronic underinvestment in public health services at both a national and global level. Of course, none of us realised just how quickly these gaps would be exposed by COVID-19, which struck just 3 months later.
Given the devastating impact the pandemic has had over the last 2 years, the publication of the Lancet Global Heath Commission on financing primary health care3Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Global Health. 2022; ( published online April 4.) https: //doi.org/10.1016/S2214-109X ( 22) 00005-5Google Scholar is most timely and welcome. This excellent report argues strongly that the COVID-19 crisis shows that we need to invest more in health, but that as well as spending more, we need to spend better.
Building on the seminal World Health Report of 2010,4World Health OrganizationHealth systems financing: the path to universal coverage. The World Health Report.https: //www.who.int/publications/i/item/9789241564021Date: 2010Date accessed: March 24, 2022Google Scholar the Commission3Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Global Health. 2022; ( published online April 4.) https: //doi.org/10.1016/S2214-109X ( 22) 00005-5Google Scholar shows that in raising financing for a nation's health system, pooled public financing mechanisms are superior to private voluntary mechanisms such as health-care user fees and private insurance schemes. This is because only public financing can ensure that everybody, including the poor, receives the health services they need.
With all countries facing constraints in public financing, it is essential that pooled public funds are spent as efficiently and equitably as possible, to maximise health benefits for the most people. To do this, it is necessary to invest in the most cost-effective health interventions that prevent people from becoming ill or enable them to be treated quickly in the community or a primary care setting, before they require costly hospital care.
Over recent decades, extensive research has shown that better value for money is achieved from public health spending, in terms of higher health outcomes, when it is allocated to PHC services. As well as services provided by health centres, this should include investing in community-based services delivered by publicly-financed community health workers, whose value has been shown since the days of China's famous barefoot doctors.
Over the last 2 years, community-health workers have also proved extremely effective in tackling the pandemic by mobilising communities and providing preventive and curative services. It is therefore encouraging to see more countries, such as South Africa,5Africa UnionThe critical role of community health workers in COVID-19 vaccine roll out.https: //africacdc.org/download/the-critical-role-of-community-health-workers-in-covid-19-vaccine-roll-out/Date: 2021Date accessed: March 25, 2022Google Scholar recognising the value of community health workers and formalising their employment by the state.
As well as improving people's access to health services, public investment PHC services also fulfils an important role in protecting vulnerable people from the potentially high costs of health care, which is an explicit objective of UHC.
Whereas some might think that financial protection is best achieved by protecting people from the sudden high costs of inpatient hospital care, there is evidence from many countries6Selvaraj S Farooqui HH Karan A Quantifying the financial burden of households ' out-of-pocket payments on medicines in India: a repeated cross-sectional analysis of National Sample Survey data, 1994–2014.BMJ Open. 2018; 8e018020Google Scholar that the highest burden of out-of-pocket expenditure is actually from people purchasing medicines, often from private drug stores. Therefore, potentially the best way to reduce impoverishing health-care costs would be to publicly finance the provision of medicines in PHC and community settings.
Moreover, as there is strong evidence that private financing of medicines ( often spent on inappropriate use of antibiotics) is highly correlated with growing levels of antimicrobial resistance, this points to the need to publicly finance medicines to reduce the threat of antimicrobial resistance.
This latter point also shows that as well as helping improving the health of individuals, investing in PHC also helps strengthen our collective health security. PHC is the foundation of a strong health system and is where a lot of infectious disease interventions ( eg, surveillance, prevention, and treatment) are delivered.
As we rebuild after COVID-19 and countries aim to strengthen their preparedness against future pandemics, it is essential that vital public health services are funded properly and integrated into broader UHC reforms that are PHC-led. Ultimately this will prove the most efficient and equitable way to simultaneously strengthen health security and accelerate progress towards UHC.
Gro Harlem Brundtland is a former Director-General of the World Health Organization and a founding member of The Elders.
The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care ( PHC) into sharp focus. PHC is the best platform for providing basic health interventions ( including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open Access | tech |
Definition, diagnosis, and management of COVID-19-associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India - The Lancet Infectious Diseases | COVID-19-associated pulmonary mucormycosis ( CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus ( ≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B ( 5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4–6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required.
COVID-19-associated pulmonary mucormycosis ( CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus ( ≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B ( 5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4–6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required.
The COVID-19 pandemic precipitated an epidemic of mucormycosis worldwide, especially in India.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Google Scholar Traditionally, the site of involvement of mucormycosis is related to the underlying predisposing factors. Rhino-orbital mucormycosis occurs in uncontrolled diabetes, whereas pulmonary mucormycosis is seen in patients with haematological malignancy and transplant recipients.2Prakash H Chakrabarti A Global epidemiology of mucormycosis.J Fungi ( Basel). 2019; 5: 26Google Scholar During the COVID-19-associated mucormycosis ( CAM) outbreak, rhino-orbital mucormycosis was the most common manifestation, followed by pulmonary mucormycosis.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Google Scholar, 4Hussain S Riad A Singh A et al.Global prevalence of COVID-19-associated mucormycosis ( CAM): living systematic review and meta-analysis.J Fungi ( Basel). 2021; 7: 985Google Scholar, 5Hussain S Baxi H Riad A et al.COVID-19-associated mucormycosis ( CAM): an updated evidence mapping.Int J Environ Res Public Health. 2021; 1810340Google Scholar Among the various risk factors for rhino-orbital mucormycosis and pulmonary mucormycosis, uncontrolled diabetes overshadowed all others.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Google Scholar In two large multicentre cohort studies from India, pulmonary mucormycosis accounted for 13·3% of the total patients with mucormycosis before the COVID-19 pandemic, and 8·6% of the total patients with mucormycosis during the COVID-19 pandemic.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Google Scholar, 6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Google Scholar The lower proportion of patients with pulmonary mucormycosis during the CAM outbreak could be due to the difficulty in diagnosis of and little awareness of pulmonary mucormycosis.7Muthu V Agarwal R Dhooria S et al.Has the mortality from pulmonary mucormycosis changed over time? A systematic review and meta-analysis.Clin Microbiol Infect. 2021; 27: 538-549Google Scholar Often, pulmonary mucormycosis is either not suspected or remains undiagnosed ( due to inadequate infrastructure), despite clinical suspicion. The disruption of diagnostic and clinical services during the COVID-19 pandemic further compounded the difficulties in diagnosing COVID-19-associated pulmonary mucormycosis ( CAPM).8Garg D Muthu V Sehgal IS et al.Coronavirus disease ( Covid-19) associated mucormycosis ( CAM): case report and systematic review of literature.Mycopathologia. 2021; 186: 289-298Google Scholar, 9Pandey N Kaushal V Puri GD et al.Transforming a general hospital to an infectious disease hospital for COVID-19 over 2 weeks.Front Public Health. 2020; 8: 382Google Scholar Although there are global guidelines for the management of mucormycosis,10Rudramurthy SM Hoenigl M Meis JF et al.ECMM/ISHAM recommendations for clinical management of COVID-19 associated mucormycosis in low- and middle-income countries.Mycoses. 2021; 64: 1028-1037Google Scholar, 11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Google Scholar there is no clear guidance on the diagnosis and treatment of pulmonary mucormycosis, including CAPM. We framed the current consensus statement to address the diagnosis and management of CAPM and to identify the knowledge gaps in this area.
We formed a CAPM clinical practice guideline group ( CAPM-GG), including experts from the Fungal Infection Study Forum and the Academy of Pulmonary Sciences in India. We selected experts, with specific interest in mucormycosis who were actively involved in managing CAPM and pulmonary mucormycosis, from various disciplines, including pulmonary medicine, infectious diseases, clinical mycology, pathology, radiodiagnosis, and thoracic surgery to be part of CAPM-GG. At the outset, the experts were briefed on the objectives of the CAPM-GG and the Delphi process ( appendix p 5). For the systematic review, two authors ( RA and VM) searched PubMed and Embase databases ( from inception to Sept 25, 2021) using the search terms: ( “ COVID ” OR “ SARS-CoV ” OR “ coronavirus ”) AND ( mucor * OR “ zygomycosis ”). The references obtained from the search were imported into a reference manager software. Our search retrieved 306 articles. We excluded abstracts, articles in a language other than English, and animal studies. After excluding duplicate citations, we reviewed 236 articles in detail ( appendix pp 9–25). We reviewed the articles reporting cases of CAPM, relevant review articles, large series of CAM, and our personal files to identify the questions to be addressed ( appendix pp 26–30). On the basis of the literature review, three authors ( VM, RA, and AC) formulated the initial questions. The questions were circulated by e-mail, and additional questions were invited from the CAPM-GG.
Subsequently, we followed a modified Delphi method ( appendix p 5). We used the commercially available, web-based Delphi platform for circulating the questions and receiving anonymous responses from the participants. The Delphi process was continued until the predefined criteria of consensus ( ≥70% agreement or disagreement on a statement) was achieved, or for a maximum of three rounds. After each round of Delphi, we held virtual meetings to discuss the unresolved issues. The comments received during the two rounds and the virtual discussions were incorporated into the final round of Delphi. We recorded the responses to statements using a five-point Likert scale: strongly agree, somewhat agree, neutral, somewhat disagree, and strongly disagree. For the statements for which a response was recorded using the Likert sale, the categories strongly agree and somewhat agree, or strongly disagree and somewhat disagree, were considered together. We recommend a course of action for statements for which consensus of 70% or more was reached and suggest a course of actions for those with a consensus of less than 70%, and provided the consensus level for important summary statements. Statements failing to achieve the predefined consensus criteria even after the final meeting were recorded as dissensus.
The online surveys and meetings were conducted between Oct 1 and Nov 1, 2021. 26 of the 28 invited experts participated in the survey. The CAPM-GG comprised experts from pulmonary medicine ( 13 [ 50% ]), infectious diseases ( six [ 23% ]), clinical mycology ( three [ 12% ]), radiodiagnosis ( two [ 8% ]), pathology ( one [ 4% ]), and thoracic surgery ( one [ 4% ]), belonging to either public sector ( 14 [ 54% ]) or private sector ( 12 [ 46% ]) institutes across the country. The results of the Delphi process are presented in table 1. We achieved a consensus for 84 of the 89 statements, based on which we provide various clinical practice statements for different questions on CAPM.Table 1Results of the Delphi process for the various statements on different questions concerning CAPMSurvey responseConsensus level (%) Definition of CAPMProven CAPMYes100% Probable CAPMYes100% Possible CAPMYes75% Risk factorsUncontrolled diabetesYes100% Inappropriate steroid therapyYes100% Severe COVID-19Yes78% ImmunosuppressionYes95% Immunomodulators for COVID-19 ( eg, tocilizumab) Yes28% Altered iron metabolismYes78% ICU admission for COVID-19No85% Use of industrial oxygen, contaminated humidifier water, or reused masksNo65% No or irregular use of a mask during COVID-19 or post-COVID-19 periodNo79% Zinc supplement for COVID-19No75% Clinical featuresFeverSuggestive83% Worsening or productive coughSuggestive87% Brownish or black sputumHighly suggestive74% Chest painSuggestive71% HaemoptysisHighly suggestive70% Worsening respiratory symptoms patients with COVID-19Suggestive83% Worsening chest imagingSuggestive70% Evaluation of CAPMCharacteristic imaging on CT with intravenous contrastYes100% Routine imaging of paranasal sinuses or brainNo89% Respiratory sample positive for Mucorales by conventional diagnostic techniquesYes100% Bronchoalveolar lavage sample positive for Mucorales by molecular diagnostic techniquesYes74% SerologyNo83% Molecular test of blood, urine, or body fluidNo58% Imaging findingsReversed halo signHighly suggestive100% Thick-walled cavityHighly suggestive94% Large consolidation or necrotising pneumoniaHighly suggestive81% Mycotic aneurysmHighly suggestive100% Bird's nest signHighly suggestive95% Multiple large nodulesHighly suggestive72% Serial imaging showing air-fluid levelsSuggestive80% Pleural effusion associated with other findingsSuggestive74% PneumothoraxNon-specific100% Mediastinal lymphadenopathyNot suggestive89% Centrilobular nodules or tree in bud appearanceNot suggestive100% Differential diagnosisSevere COVID-19Yes82% COVID-19-associated pulmonary aspergillosisYes100% TuberculosisYes96% Other cavitary pneumoniasYes75% Bacterial pneumonia ( community and hospital acquired) Yes86% Diagnostic proceduresOpen-lung biopsy for diagnosisNo73% Diagnostic bronchoscopy should be performed as early as possible for the evaluation of suspected CAPMYes95% Flexible bronchoscopy can be safely performed in all patients with COVID-19 ( intubated and non-intubated), following standard precautionsYes78% CT-guided trucut biopsy ( or fine-needle aspiration with on-site evaluation) Yes91% Laboratory processing of samplesUse of high-volume samplesYes85% Rapid transport to the laboratoryYes90% Use of Calcofluor microscopical examinationYes72% Semiquantitative estimation of fungusNot recommended85% Mincing ( instead of grinding) the tissue sampleYes87% PCR from surgical or biopsy specimens for bronchoalveolar lavage fluidYes74% The histopathology of CAPM is not different from non-CAPMYes90% Immunohistochemistry is useful in differentiating mucormycosis from aspergillosis in tissuesYes61% Species identification and antifungal susceptibilityDoes species identification help in the management? Yes74% Is an antifungal susceptibility test essential for optimal therapy? Yes71% Choice of drug and doseLiposomal amphotericin B is the treatment of choice for CAPMYes100% If liposomal formulation is unavailable, any lipid formulation can be usedYes100% If no lipid formulation is available, amphotericin B deoxycholate should be used as the primary therapy over posaconazole or isavuconazoleYes94% Initial dose of intravenous liposomal amphotericin B5 mg/kg80% Should the amphotericin B dose be escalated in bilateral or non-operable disease? No85% Should the amphotericin B dose be escalated in the presence of uncontrolled risk factors for CAPM? No90% Should the amphotericin B dose be escalated in the presence of extrapulmonary mucormycosis ( disseminated or ROCM)? No52% After complete or partial response is achieved, maintenance treatment with isavuconazole or posaconazole should be givenYes100% Preferred formulation of posaconazole is a tabletYes80% Therapeutic drug monitoring of posaconazoleYes74% Combination of antifungalsThe combination of antifungals ( posaconazole or isavuconazole with amphotericin) is not evidence based and should not be recommendedYes89% Echinocandins in combination with amphotericin B can be given in CAPMNo83% Salvage therapy with posaconazole or isavuconazole might be considered in refractory patientsYes100% Nebulised amphotericin B for CAPMNo95% Response monitoring and duration of therapyDuration of therapy should be based on response assessment ( instead of a fixed duration) Yes81% Monitoring with a weekly chest radiography ( along with antifungals as and when required) Yes95% Preferred timing of CT scan for response assessment4–6 weeks70% Surgery For CAPMAll patients with potentially resectable disease of the lung ( unilateral) should undergo surgeryYes95% Preoperative multidisciplinary team evaluationYes100% Timing of surgery after diagnosis * After stabilising the metabolic derangements.As early as possible ( < 1 week); < 2 weeks34%; 40% Spirometry desirable in all patients preoperatively, especially before pneumonectomy or in those with pre-existing lung diseaseYes100% Surrogate tests such as 6-MWT or other methods are sufficient to assess exercise capacity ( if spirometry not possible) Yes90% Preoperative assessment of frailtyYes82% Delay surgery or continue medical management and reassess in frail patientsYes89% Surgery for CAPM in the presence of COVID-19-related lung disease†Except in patients with emergent indications such as massive haemoptysis.After stabilistion80% Extensive invasion of mediastinal structures and hilar vessels seen on thoracic imaging is associated with technical difficulties during surgery and poor outcome; hence, initial medical management followed by reassessment is suggestedAgreed81% Prevention of CAPMProphylactic antifungals or nebulised amphotericin B to prevent CAPM in patients with COVID-19 admitted to hospital or the ICUNo91% Universal maskingYes95% Avoidance of construction siteYes90% Control of blood sugars in diabetesYes100% Immunosuppression for COVID-19, optimal dose, and durationYes95% Severe COVID-19 and development of CAPM before 10 days of therapy with glucocorticoidsStop therapy71% No glucocorticoid use for non-severe ( non-hypoxaemic) COVID-19Yes100% Judicious use of corticosteroids for post-COVID-19 lung disease ( at the lowest possible dose for the shortest possible duration) Yes78% CAPM=COVID-19-associated pulmonary mucormycosis. 6-MWT=6 min walk test. CAPA=COVID-19-associated pulmonary aspergillosis. ICU=intensive care unit. ROCM=rhinoorbitocerebral mucormycosis. * After stabilising the metabolic derangements.† Except in patients with emergent indications such as massive haemoptysis. Open table in a new tab
CAPM=COVID-19-associated pulmonary mucormycosis. 6-MWT=6 min walk test. CAPA=COVID-19-associated pulmonary aspergillosis. ICU=intensive care unit. ROCM=rhinoorbitocerebral mucormycosis.
Pulmonary mucormycosis diagnosed either at the same time as, or within 3 months of, confirmed COVID-19 was agreed upon as the entry criterion for diagnosing CAPM.6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Google Scholar We further classified CAPM as proven, probable, and possible ( panel 1). The consensus for the proven and probable CAPM categories was obtained following the first round of surveys. For the possible CAPM category, we could only reach a consensus in the third round. The experts were divided in their opinions on possible CAPM, given the potential for over-diagnosis and unnecessary empirical treatment, which is both long lasting and expensive. However, we retained the possible CAPM category, recognising the need for an epidemiological definition for facilitating research and adopting a judicious treatment approach. Furthermore, the group emphasised that an extensive evaluation of possible CAPM should be undertaken by performing bronchoscopy or other suitable diagnostic procedures to confirm or exclude the diagnosis.Panel 1Definitions of COVID-19 associated pulmonary mucormycosisCOVID-19-associated pulmonary mucormycosis ( CAPM) is diagnosed either simultaneously with or within 3 months of virologically confirmed COVID-19.Proven CAPMHistopathology or cytology showing aseptate hyphae or culture obtained by a sterile procedure from a usually sterile site ( pleural fluid or lung) showing growth of Mucorales.Probable CAPMPresence of all the following: compatible clinical features, risk factors, and suggestive imaging ( thick-walled cavity, large consolidation, reversed halo sign, or multiple large nodules) and demonstration of aseptate hyphae ( with or without growth of Mucorales) in a sample representative of the lower respiratory tract ( including bronchoalveolar lavage, non-bronchoscopic bronchial lavage, bronchial washings, bronchial brushing, endotracheal aspirates, and sputum).Possible CAPMPresence of all the following: compatible clinical features; uncontrolled diabetes, prolonged or inappropriate glucocorticoid therapy ( dose, duration, or indication deviating from the current evidence-based practice for glucocorticoids in COVID-19); and highly suggestive radiology ( reversed halo sign, mycotic aneurysm, or thick-walled cavity), in the absence of a definite alternative diagnosis.
COVID-19-associated pulmonary mucormycosis ( CAPM) is diagnosed either simultaneously with or within 3 months of virologically confirmed COVID-19.
Histopathology or cytology showing aseptate hyphae or culture obtained by a sterile procedure from a usually sterile site ( pleural fluid or lung) showing growth of Mucorales.
Presence of all the following: compatible clinical features, risk factors, and suggestive imaging ( thick-walled cavity, large consolidation, reversed halo sign, or multiple large nodules) and demonstration of aseptate hyphae ( with or without growth of Mucorales) in a sample representative of the lower respiratory tract ( including bronchoalveolar lavage, non-bronchoscopic bronchial lavage, bronchial washings, bronchial brushing, endotracheal aspirates, and sputum).
Presence of all the following: compatible clinical features; uncontrolled diabetes, prolonged or inappropriate glucocorticoid therapy ( dose, duration, or indication deviating from the current evidence-based practice for glucocorticoids in COVID-19); and highly suggestive radiology ( reversed halo sign, mycotic aneurysm, or thick-walled cavity), in the absence of a definite alternative diagnosis.
The prevalence of CAPM was reported to be 0·01% in patients with COVID-19 from the community ( data from one centre in Mexico), 0·15% in patients admitted to hospital with COVID-19 ( data from five tertiary-care centres in India), and 1·00% in patients with COVID-19 on mechanical ventilation ( data from 59 micology laboratories in France).6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Google Scholar, 12Guzman-Castro S Chora-Hernandez LD Trujillo-Alonso G et al.COVID-19-associated mucormycosis, diabetes and steroid therapy: experience in a single centre in western Mexico.Mycoses. 2021; 65: 65-70Google Scholar, 13Gangneux JP Dannaoui E Fekkar A et al.Fungal infections in mechanically ventilated patients with COVID-19 during the first wave: the French multicentre MYCOVID study.Lancet Respir Med. 2021; 10: 180-190Google Scholar The burden of CAPM following the second wave of the COVID-19 pandemic in India and other countries remains largely unknown.14Ramaswami A Sahu AK Kumar A et al.COVID-19-associated mucormycosis presenting to the emergency department-an observational study of 70 patients.QJM. 2021; 114: 464-470Google Scholar, 15Selarka L Sharma S Saini D et al.Mucormycosis and COVID-19: an epidemic within a pandemic in India.Mycoses. 2021; 64: 1253-1260Google Scholar, 16Seidel D Simon M Sprute R et al.Results from a national survey on COVID-19-associated mucormycosis in Germany: 13 patients from six tertiary hospitals.Mycoses. 2021; 65: 103-109Google Scholar, 17Bayram N Ozsaygılı C Sav H et al.Susceptibility of severe COVID-19 patients to rhino-orbital mucormycosis fungal infection in different clinical manifestations.Jpn J Ophthalmol. 2021; 65: 515-525Google Scholar
In a systematic review, CAPM accounted for 26 ( 9·5%) of 275 patients with CAM from across the world.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Google Scholar 17 ( 7·3%) of 233 reported CAM cases from India and nine ( 21·4%) of 42 reported CAM cases from the rest of the world were due to CAPM.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Google Scholar On the basis of the scarce data available from India,6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Google Scholar France,18Danion F Letscher-Bru V Guitard J et al.COVID-19 associated mucormycosis in France: a rare but deadly complication.Open Forum Infect Dis. 2021; 9ofab566Google Scholar and Chile,19Rabagliati R Rodríguez N Núñez C Huete A Bravo S Garcia P COVID-19-associated mold infection in critically ill patients, Chile.Emerg Infect Dis. 2021; 27: 1454-1456Google Scholar the pooled prevalence of CAPM was estimated to be 5 ( 95% CI < 1 to 29) per 10 000 patients admitted to hospital with COVID-19 ( appendix p 6). The prevalence of CAPM was higher in India and Chile than in France. After the second wave of COVID-19, India reported more than 40 000 patients with CAM. The experts estimated that the number of patients with CAPM in the recent CAM epidemic should have been around 4000. However, no more than 40 incidents of CAPM have been published globally.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Google Scholar, 20Alfishawy M Elbendary A Younes A et al.Diabetes mellitus and coronavirus disease ( Covid-19) associated mucormycosis ( CAM): a wake-up call from Egypt.Diabetes Metab Syndr. 2021; 15102195Google Scholar, 21Chennamchetty VK Adimulapu S Kola BP et al.Post-COVID pulmonary mucormycosis—a case report.IP Indian J Immunol Respir Med. 2021; 6: 62-66Google Scholar, 22Dantis K Rathore V Kashyap NK Gupta N De S Singha SK SARS-CoV-2 sequel: pulmonary mucormycosis with a mycotic aneurysm in a transplant recipient.Tuberc Respir Dis ( Seoul). 2021; 84: 335-337Google Scholar, 23Rabagliati R Rodríguez N Núñez C Huete A Bravo S Garcia P Covid-19-associated mold infection in critically ill patients, chile.Emerg Infect Dis. 2021; 27: 1454-1456Google Scholar, 24Rana G Gautam S Mawari G Daga MK Kumar N Raghu RV Massive hemoptysis causing mortality in a post COVID-19 infected Asian male patient: presenting as pulmonary mucormycosis, pulmonary tuberculosis and later sino-nasal mucormycosis.Respir Med Case Rep. 2021; 34101511Google Scholar Thus, there is a possibility of gross under-reporting of the number of patients with CAPM.
All participants considered uncontrolled diabetes ( hyperglycaemia) and inappropriate ( or excessive) glucocorticoid therapy as major risk factors for CAPM.25Cornely OA Duarte RF Haider S et al.Phase 3 pharmacokinetics and safety study of a posaconazole tablet formulation in patients at risk for invasive fungal disease.J Antimicrob Chemother. 2016; 71: 718-726Google Scholar, 26Riad A Shabaan AA Issa J et al.COVID-19-associated mucormycosis ( CAM): case-series and global analysis of mortality risk factors.J Fungi. 2021; 7: 837Google Scholar COVID-19 per se, and the associated dysregulation of iron metabolism, were also considered to be contributing factors.27Kumar HM Sharma P Rudramurthy SM et al.Serum iron indices in COVID-19-associated mucormycosis: a case-control study.Mycoses. 2021; 65: 120-127Google Scholar Although patients with COVID-19 requiring intensive care have been noted to develop CAPM,13Gangneux JP Dannaoui E Fekkar A et al.Fungal infections in mechanically ventilated patients with COVID-19 during the first wave: the French multicentre MYCOVID study.Lancet Respir Med. 2021; 10: 180-190Google Scholar, 16Seidel D Simon M Sprute R et al.Results from a national survey on COVID-19-associated mucormycosis in Germany: 13 patients from six tertiary hospitals.Mycoses. 2021; 65: 103-109Google Scholar most experts believed that intensive care was not an independent risk factor. The CAPM-GG did not consider zinc supplementation, contaminated humidifiers, industrial oxygen, or reused masks as risk factors for CAPM.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Google Scholar, 28Muthu V Kumar M Paul RA et al.Is there an association between zinc and COVID-19-associated mucormycosis? Results of an experimental and clinical study.Mycoses. 2021; 64: 1291-1297Google Scholar The experts also found insufficient evidence to indicate tocilizumab or other immunomodulators as risk factors for CAPM.6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Google Scholar
None of the clinical features were found to be specific to CAPM, and the presentation of CAPM is often indistinguishable from COVID-19 or any pneumonic illness.29Hoenigl M Seidel D Carvalho A et al.The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries.Lancet Microbe. 2022; ( published online Jan 25.) https: //doi.org/10.1016/S2666-5247 ( 21) 00237-8Google Scholar The presence of brownish or black sputum and haemoptysis in a patient with COVID-19, particularly in the presence of risk factors ( as mentioned earlier), should trigger investigations for CAPM.30Pruthi H Muthu V Bhujade H et al.Pulmonary artery pseudoaneurysm in COVID-19-associated pulmonary mucormycosis: case series and systematic review of the literature.Mycopathologia. 2021; 187: 31-37Google Scholar Other suggestive features include chest pain; fever despite antibiotic therapy for at least 48 h; worsening or productive cough; cavity; or worsening alveolar shadows on a chest x-ray in the appropriate setting ( eg, a patient with uncontrolled diabetes).
Early detection of mucormycosis determines patient outcomes. In this context, CT of the chest is superior to chest x-ray. Mucorales, unlike Aspergillus, rarely colonise the respiratory tract.31Lass-Flörl C Salzer GM Schmid T Rabl W Ulmer H Dierichi MP Pulmonary Aspergillus colonization in humans and its impact on management of critically ill patients.Br J Haematol. 1999; 104: 745-747Google Scholar, 32Ribes JA Vanover-Sams CL Baker DJ Zygomycetes in human disease.Clin Microbiol Rev. 2000; 13: 236-301Google Scholar, 33Lass-Flörl C Zygomycosis: conventional laboratory diagnosis.Clin Microbiol Infect. 2009; 15: 60-65Google Scholar Thus, the isolation of Mucorales from sputum or endotracheal aspirate signifies probable mucormycosis in the presence of compatible clinicoradiological features. Sputum examination is a non-invasive procedure and can be considered the initial investigation. The diagnostic yield might be higher with respiratory samples obtained using bronchoscopy because they are more representative of the disease site. In a study of 24 patients with confirmed pulmonary mucormycosis, three were diagnosed with sputum examination, whereas nine were diagnosed with bronchoscopy.34Peng M Meng H Sun Y et al.Clinical features of pulmonary mucormycosis in patients with different immune status.J Thorac Dis. 2019; 11: 5042-5052Google Scholar No specific serological markers are available for mucormycosis. Serum galactomannan and β-D-glucan are useful in diagnosing COVID-19-associated pulmonary aspergillosis ( CAPA), a close mimic of CAPM. Importantly, dual infections of CAPM and CAPA might also be encountered.35Bellanger AP Navellou JC Lepiller Q et al.Mixed mold infection with Aspergillus fumigatus and Rhizopus microsporus in a severe acute respiratory syndrome coronavirus 2 ( SARS-CoV-2) patient.Infect Dis Now. 2021; 51: 633-635Google Scholar, 36Johnson AK Ghazarian Z Cendrowski KD Persichino JG Pulmonary aspergillosis and mucormycosis in a patient with COVID-19.Med Mycol Case Rep. 2021; 32: 64-67Google Scholar
We recommend CT with intravenous contrast and conventional microbiological testing from the lower respiratory tract samples as the initial steps in evaluating CAPM ( consensus level: 100%).
A chest x-ray is often the initial imaging available, and non-specific signs such as consolidation, cavities, and pleural effusion might be encountered. A CT of the thorax is thus required to delineate the abnormalities and guide diagnostic procedures. The imaging of CAPM has a wide differential diagnosis, including CAPA, tuberculosis, other bacterial pneumonia, and even severe COVID-19.37Yılmaz Demirci N Uğraş Dikmen A Taşçı C et al.Relationship between chest computed tomography findings and clinical conditions of coronavirus disease ( COVID-19): a multicentre experience.Int J Clin Pract. 2021; 75e14459Google Scholar The presence of a halo sign, a reversed halo sign ( RHS), an air crescent sign, a hypodense sign, and cavitating nodules help to differentiate invasive mould infections from other pneumonias.38Alexander BD Lamoth F Heussel CP et al.Guidance on imaging for invasive pulmonary aspergillosis and mucormycosis: from the imaging working group for the revision and update of the consensus definitions of fungal disease from the EORTC/MSGERC.Clin Infect Dis. 2021; 72: S79-S88Google Scholar Although a cavity on imaging might be seen in vasculitis or malignancy, the setting of COVID-19, serial imaging, and the doubling time of the lesions are important differentiating features of CAPM.
The presence of COVID-19-related lung abnormalities on imaging poses additional challenges in the diagnosis of CAPM ( appendix p 7). COVID-19 has been shown to cause both the halo sign and RHS; the prevalence of both signs varies from 0 to 18% in different series.37Yılmaz Demirci N Uğraş Dikmen A Taşçı C et al.Relationship between chest computed tomography findings and clinical conditions of coronavirus disease ( COVID-19): a multicentre experience.Int J Clin Pract. 2021; 75e14459Google Scholar, 39Sales AR Casagrande EM Hochhegger B Zanetti G Marchiori E The reversed halo sign and COVID-19: possible histopathological mechanisms related to the appearance of this imaging finding.Arch Bronconeumol. 2021; 57: 73-75Google Scholar These signs occur early in COVID-19 pneumonia. Serial imaging studies in haematological malignancies suggest halo sign to be an early feature of pulmonary mucormycosis.40Nam BD Kim TJ Lee KS Kim TS Han J Chung MJ Pulmonary mucormycosis: serial morphologic changes on computed tomography correlate with clinical and pathologic findings.Eur Radiol. 2018; 28: 788-795Google Scholar, 41Hammer MM Madan R Hatabu H Pulmonary mucormycosis: radiologic features at presentation and over time.AJR Am J Roentgenol. 2018; 210: 742-747Google Scholar By contrast, CAPM most often occurs in patients with diabetes following COVID-19 and thus resembles pulmonary mucormycosis occurring in patients with diabetes rather than haematological malignancies.30Pruthi H Muthu V Bhujade H et al.Pulmonary artery pseudoaneurysm in COVID-19-associated pulmonary mucormycosis: case series and systematic review of the literature.Mycopathologia. 2021; 187: 31-37Google Scholar, 42Garg M Prabhakar N Muthu V et al.CT Findings of COVID-19-associated pulmonary mucormycosis: a case series and literature review.Radiology. 2022; 302: 214-217Google Scholar, 43Muthu V Agarwal R Cavity in pulmonary mucormycosis: is it rare?.Trop Doct. 2021; 51: 673Google Scholar, 44Agarwal R Kumar V Gupta D Pulmonary mucormycosis: two of a kind.Eur J Intern Med. 2006; 17: 63-65Google Scholar The presentation in CAPM could be indolent,30Pruthi H Muthu V Bhujade H et al.Pulmonary artery pseudoaneurysm in COVID-19-associated pulmonary mucormycosis: case series and systematic review of the literature.Mycopathologia. 2021; 187: 31-37Google Scholar, 45Iqbal N Irfan M Jabeen K Kazmi MM Tariq MU Chronic pulmonary mucormycosis: an emerging fungal infection in diabetes mellitus.J Thorac Dis. 2017; 9: e121-e125Google Scholar and not as aggressive as in haematological malignancies. Additionally, most patients with CAPM present relatively late ( usually > 7 days after the onset of COVID-19), and the halo sign is not commonly seen at the time of diagnosis.42Garg M Prabhakar N Muthu V et al.CT Findings of COVID-19-associated pulmonary mucormycosis: a case series and literature review.Radiology. 2022; 302: 214-217Google Scholar Furthermore, serial imaging can help in differentiating between COVID-19 and CAPM. The halo sign and RHS due to COVID-19 tend to improve over time,46Wu J Tang J Zhang T Chen YC Du C Follow-up CT of “ reversed halo sign ” in SARS-CoV-2 delta VOC pneumonia: a report of two cases.J Med Virol. 2021; 94: 1289-1291Google Scholar whereas in pulmonary mucormycosis, cavitation is the usual course.40Nam BD Kim TJ Lee KS Kim TS Han J Chung MJ Pulmonary mucormycosis: serial morphologic changes on computed tomography correlate with clinical and pathologic findings.Eur Radiol. 2018; 28: 788-795Google Scholar, 41Hammer MM Madan R Hatabu H Pulmonary mucormycosis: radiologic features at presentation and over time.AJR Am J Roentgenol. 2018; 210: 742-747Google Scholar Thus, the timing, clinical setting ( uncontrolled diabetes, persistent or new-onset fever, haemoptysis, or productive cough), and the course of disease help to differentiate acute COVID-19 from CAPM.
We classified the different imaging features of CAPM as highly suggestive, suggestive, non-specific, or not suggestive ( panel 2), on the basis of the existing evidence and responses received from the CAPM-GG. The presence of a thick-walled cavity, bird's nest sign, RHS, and other features were considered as highly suggestive of CAPM ( appendix p 7), compared with the presence of multiple nodules ( described in patients with pulmonary mucormycosis with haematological malignancies).47Chamilos G Marom EM Lewis RE Lionakis MS Kontoyiannis DP Predictors of pulmonary zygomycosis versus invasive pulmonary aspergillosis in patients with cancer.Clin Infect Dis. 2005; 41: 60-66Google Scholar Digital subtraction angiography might be required in patients with a mycotic aneurysm ( appendix p 7).Panel 2CT findings of COVID-19-associated pulmonary mucormycosisHighly suggestive•Thick-walled cavity•Reversed halo sign•Large consolidation or necrotising pneumonia•Mycotic aneurysm•Bird's nest sign•Multiple large nodules ( nodules > 1 cm) •Serial imaging showing cavity with an air-fluid levelSuggestive•Pleural effusionNon-specific•PneumothoraxNot suggestive•Enlarged mediastinal lymph nodes•Centrilobular nodules or tree-in-bud appearance ( could be seen in patients with haemoptysis or in patients with coexisting COVID-19-associated pulmonary aspergillosis)
The portal of entry and risk factors are the same for both pulmonary mucormycosis and rhino-orbital mucormycosis, yet disseminated disease was reported in only three of the 20 patients with CAPM.29Hoenigl M Seidel D Carvalho A et al.The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries.Lancet Microbe. 2022; ( published online Jan 25.) https: //doi.org/10.1016/S2666-5247 ( 21) 00237-8Google Scholar Notably, all the patients were symptomatic for rhino-orbital mucormycosis. Thus, the presence of clinical features should guide evaluation of mucormycosis at other sites ( paranasal sinuses) in patients with CAPM rather than routine imaging.
The presence of RHS, thick-walled cavity, bird's nest sign, mycotic aneurysm, large consolidation, or necrotising pneumonia, and multiple large nodules ( nodules > 1 cm) and serial imaging showing cavity with an air-fluid level, were considered highly suggestive imaging features of CAPM in the appropriate clinical setting ( consensus level: 72–100%). We do not recommend routine imaging of the paranasal sinuses or brain in patients with CAPM ( consensus level: 89%).
Flexible bronchoscopy can be performed in patients with COVID-19 at any time, adhering to standard precautions.48Torrego A Pajares V Fernández-Arias C Vera P Mancebo J Bronchoscopy in patients with COVID-19 with invasive mechanical ventilation: a single-center experience.Am J Respir Crit Care Med. 2020; 202: 284-287Google Scholar, 49Gao CA Bailey JI Walter JM et al.Bronchoscopy on intubated patients with COVID-19 is associated with low infectious risk to operators.Ann Am Thorac Soc. 2021; 18: 1243-1246Google Scholar, 50Chang SH Jiang J Kon ZN et al.Safety and efficacy of bronchoscopy in critically ill patients with coronavirus disease 2019.Chest. 2021; 159: 870-872Google Scholar, 51Chhajed PN Nene A Abhyankar N et al.Conventional flexible bronchoscopy during the COVID pandemic: a consensus statement from the Indian Association for Bronchology.Lung India. 2021; 38: S105-S115Google Scholar, 52Koehler P Cornely OA Kochanek M Bronchoscopy safety precautions for diagnosing COVID-19 associated pulmonary aspergillosis—a simulation study.Mycoses. 2021; 64: 55-59Google Scholar Bronchoscopy and bronchoalveolar lavage with 60 mL of saline has been safely done even in patients with severe acute respiratory distress syndrome due to COVID-19 ( median fractional concentration of oxygen of inspired air is 0·8 and positive end-expiratory pressure of 10 cm of water).48Torrego A Pajares V Fernández-Arias C Vera P Mancebo J Bronchoscopy in patients with COVID-19 with invasive mechanical ventilation: a single-center experience.Am J Respir Crit Care Med. 2020; 202: 284-287Google Scholar The median time of occurrence of CAPM following COVID-19 ranges from 2 to 3 weeks6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Google Scholar, 30Pruthi H Muthu V Bhujade H et al.Pulmonary artery pseudoaneurysm in COVID-19-associated pulmonary mucormycosis: case series and systematic review of the literature.Mycopathologia. 2021; 187: 31-37Google Scholar and the majority of patients are unlikely to transmit SARS-CoV-2 during this period. Preliminary data suggest that the use of bronchoscopy is safe in patients with CAPM.53Mehta R, Bansal S, Kalpakkam H. Critical COVID-19 associated pulmonary mucormycosis ( CAPM): the underreported life-threatening spectrum of the mucormycosis epidemic. Lung India ( in press).Google Scholar
Mycotic aneurysms encountered in CAPM have the potential to cause fatal or severe haemoptysis.22Dantis K Rathore V Kashyap NK Gupta N De S Singha SK SARS-CoV-2 sequel: pulmonary mucormycosis with a mycotic aneurysm in a transplant recipient.Tuberc Respir Dis ( Seoul). 2021; 84: 335-337Google Scholar, 24Rana G Gautam S Mawari G Daga MK Kumar N Raghu RV Massive hemoptysis causing mortality in a post COVID-19 infected Asian male patient: presenting as pulmonary mucormycosis, pulmonary tuberculosis and later sino-nasal mucormycosis.Respir Med Case Rep. 2021; 34101511Google Scholar, 30Pruthi H Muthu V Bhujade H et al.Pulmonary artery pseudoaneurysm in COVID-19-associated pulmonary mucormycosis: case series and systematic review of the literature.Mycopathologia. 2021; 187: 31-37Google Scholar Hence, a cautious approach is required when carrying out flexible bronchoscopy, bronchoalveolar lavage, or biopsies in patients with massive haemoptysis or mycotic aneurysms. Notably, the bronchoscopy unit should be equipped to handle emergencies, such as severe bleeding following diagnostic bronchoscopies.54Muthu V Gandra RR Dhooria S et al.Role of flexible bronchoscopy in the diagnosis of invasive fungal infections.Mycoses. 2021; 64: 668-677Google Scholar The choice of additional procedures, such as transbronchial lung biopsy ( TBLB), endobronchial biopsy, brush cytology, and others, needs to be individualised, depending on the imaging abnormalities, bronchoscopical findings, and the patient's status.54Muthu V Gandra RR Dhooria S et al.Role of flexible bronchoscopy in the diagnosis of invasive fungal infections.Mycoses. 2021; 64: 668-677Google Scholar In general, performing more than one procedure increases the diagnostic yield of bronchoscopy in CAPM, as with other diseases. Flexible bronchoscopy can be used for peripheral and non-peripheral lung lesions.54Muthu V Gandra RR Dhooria S et al.Role of flexible bronchoscopy in the diagnosis of invasive fungal infections.Mycoses. 2021; 64: 668-677Google Scholar Radial endobronchial ultrasound-guided bronchoalveolar lavage or TBLB could improve the chances of obtaining a representative specimen.54Muthu V Gandra RR Dhooria S et al.Role of flexible bronchoscopy in the diagnosis of invasive fungal infections.Mycoses. 2021; 64: 668-677Google Scholar, 55Chen CH Cheng WC Wu BR et al.Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation.J Thorac Dis. 2015; 7: S418-S425Google Scholar Importantly, endobronchial abnormalities occur in up to 79% of patients with suspected pulmonary mucormycosis undergoing diagnostic bronchoscopy.56Lin CY Wang IT Chang CC et al.Comparison of clinical manifestation, diagnosis, and outcomes of invasive pulmonary aspergillosis and pulmonary mucormycosis.Microorganisms. 2019; 7: e531Google Scholar In patients with suspected invasive mould disease based on clinical and radiological features, identification of an adherent mucus plug during bronchoscopy was noted exclusively in patients with pulmonary mucormycosis and not those with invasive pulmonary aspergillosis.54Muthu V Gandra RR Dhooria S et al.Role of flexible bronchoscopy in the diagnosis of invasive fungal infections.Mycoses. 2021; 64: 668-677Google Scholar Furthermore, invasive tracheobronchitis is a feature of fungal disease in intubated, critically ill patients, and can be diagnosed only with bronchoscopy.57Yazıcıoğlu Moçin O Karakurt Z Aksoy F et al.Bronchoscopy as an indicator of tracheobronchial fungal infection in non-neutropenic intensive-care unit patients.Clin Microbiol Infect. 2013; 19: e136-e141Google Scholar
We recommend early flexible bronchoscopy in most patients with CAPM ( consensus level: 95%) due to the following advantages: visualisation of airway abnormalities, performing endobronchial biopsies, and provision of samples representing the lower respiratory tract ( bronchoalveolar lavage or bronchial washings).
Lung biopsies obtained by video-assisted thoracoscopic surgery or thoracotomy might yield the diagnosis in suspected CAPM. However, due to the high morbidity and mortality of this test and the availability of less invasive diagnostic tests, surgical lung biopsy should rarely be used for the diagnosis of CAPM. Although both fine-needle aspiration biopsies and core-needle biopsies can be used to diagnose mould infections, a consensus was achieved for transthoracic core-needle biopsies owing to their higher diagnostic yield ( figure 1).58Watane GV Hammer MM Barile MF CT-guided core-needle biopsy of the lung Is safe and more effective than fine-needle aspiration biopsy in patients with hematologic malignancies.Radiol Cardiothorac Imaging. 2019; 1e180030Google Scholar, 59Haas BM Clayton JD Elicker BM Ordovas KG Naeger DM CT-guided percutaneous lung biopsies in patients with suspicion for infection may yield clinically useful information.AJR Am J Roentgenol. 2017; 208: 459-463Google Scholar, 60Sharma SK Kumar S Singh AK et al.Feasibility and outcome of CT-guided lung biopsy in patients with hematological diseases and suspected fungal pneumonia.J Infect Dev Ctries. 2013; 7: 748-752Google Scholar, 61Carrafiello G Laganà D Nosari AM et al.Utility of computed tomography ( CT) and of fine needle aspiration biopsy ( FNAB) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients.Radiol Med ( Torino). 2006; 111: 33-41Google Scholar The complication rates of transthoracic core-needle biopsies and fine-needle aspirates have been similar in the studies published before the COVID-19 pandemic.58Watane GV Hammer MM Barile MF CT-guided core-needle biopsy of the lung Is safe and more effective than fine-needle aspiration biopsy in patients with hematologic malignancies.Radiol Cardiothorac Imaging. 2019; 1e180030Google Scholar, 59Haas BM Clayton JD Elicker BM Ordovas KG Naeger DM CT-guided percutaneous lung biopsies in patients with suspicion for infection may yield clinically useful information.AJR Am J Roentgenol. 2017; 208: 459-463Google Scholar, 60Sharma SK Kumar S Singh AK et al.Feasibility and outcome of CT-guided lung biopsy in patients with hematological diseases and suspected fungal pneumonia.J Infect Dev Ctries. 2013; 7: 748-752Google Scholar, 61Carrafiello G Laganà D Nosari AM et al.Utility of computed tomography ( CT) and of fine needle aspiration biopsy ( FNAB) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients.Radiol Med ( Torino). 2006; 111: 33-41Google Scholar, 62Lass-Flörl C Aigner M Nachbaur D et al.Diagnosing filamentous fungal infections in immunocompromised patients applying computed tomography-guided percutaneous lung biopsies: a 12-year experience.Infection. 2017; 45: 867-875Google Scholar However, considering the possibility of severe bleeding in patients with suspected CAPM, an alternative approach of performing a fine-needle aspiration cytology with on-site cytopathological examination might be considered before proceeding with core-needle biopsies.Figure 1Diagnostic algorithm for evaluating suspected CAPMShow full captionCAPM=COVID-19-associated pulmonary mucormycosis. * Direct microscopy or histopathology showing broad aseptate hyphae.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
CAPM=COVID-19-associated pulmonary mucormycosis. * Direct microscopy or histopathology showing broad aseptate hyphae.
We recommend transthoracic trucut core-needle biopsy for diagnosing CAPM in patients with peripheral chest lesions ( consensus level: 91%).
Obtaining a high-volume sample, avoiding contamination, and ensuring rapid transport to the laboratory increases the diagnostic yield during mycological analysis. The processing of tracheal, bronchial, and bronchoalveolar lavage fluid samples in the mycology laboratory is similar. The respiratory sample is first centrifuged, and the pellet obtained is used for microscopy and culture. The use of Calcofluor-white staining improves the detection of hyphae during microscopy.33Lass-Flörl C Zygomycosis: conventional laboratory diagnosis.Clin Microbiol Infect. 2009; 15: 60-65Google Scholar Mincing the tissue samples for culture should be performed instead of grinding, because grinding compromises fungal viability. Environmental contamination of a sample obtained in a non-sterile manner could result in a positive culture for Mucorales.63Prakash H Singh S Rudramurthy SM et al.An aero mycological analysis of mucormycetes in indoor and outdoor environments of northern India.Med Mycol. 2020; 58: 118-123Google Scholar Hence, the experts considered direct microscopy to be more reliable than culture when performed from a non-sterile sample. In the presence of strong clinicoradiological suspicion, isolated growth of Mucorales ( despite negative direct smear microscopy) could represent probable CAPM. However, in the absence of a strong clinical or radiological suspicion, an isolated positive culture should be interpreted with caution, and repeating the biopsy or bronchoalveolar lavage could be warranted.
Molecular diagnostic tests from respiratory and other samples could help to diagnose CAPM. The diagnostic role of nucleic acid amplification ( NAA) tests on blood or body fluids is still unclear, and the experts did not recommend routine use of these tests for diagnosing CAPM. However, the experts acknowledged the potential usefulness of molecular tests from blood or body fluids once standardised testing methods and more evidence are available. Molecular assays from a non-sterile site should also be cautiously interpreted. NAA assays for Mucorales in a sample obtained from a sterile site provide supportive evidence for CAPM in a compatible clinical setting.64Millon L Herbrecht R Grenouillet F Morio F Alanio A Letscher-Bru V et al.Early diagnosis and monitoring of mucormycosis by detection of circulating DNA in serum: retrospective analysis of 44 cases collected through the French Surveillance Network of Invasive Fungal Infections ( RESSIF).Clin Microbiol Infect. 2016; 22: e1-e8Google Scholar, 65Millon L Scherer E Rocchi S Bellanger AP Molecular strategies to diagnose mucormycosis.J Fungi ( Basel). 2019; 5: e24Google Scholar, 66Caillot D Legouge C Lafon I et al.Retrospective study of 25 cases of pulmonary mucormycosis in acute leukaemia.Rev Mal Respir. 2018; 35 ( in French).: 452-464Google Scholar One published study in CAPM18Danion F Letscher-Bru V Guitard J et al.COVID-19 associated mucormycosis in France: a rare but deadly complication.Open Forum Infect Dis. 2021; 9ofab566Google Scholar and a few studies67Scherer E Iriart X Bellanger AP et al.Quantitative PCR ( qPCR) detection of Mucorales DNA in bronchoalveolar lavage fluid to diagnose pulmonary mucormycosis.J Clin Microbiol. 2018; 56: e00289-e00318Google Scholar, 68Guegan H Iriart X Bougnoux ME Berry A Robert-Gangneux F Gangneux JP Evaluation of MucorGenius mucorales PCR assay for the diagnosis of pulmonary mucormycosis.J Infect. 2020; 81: 311-317Google Scholar, 69Wehrle-Wieland E Affolter K Goldenberger D et al.Diagnosis of invasive mold diseases in patients with hematological malignancies using Aspergillus, Mucorales, and panfungal PCR in BAL.Transpl Infect Dis. 2018; 20e12953Google Scholar in non-CAPM suggest the potential usefulness of NAA tests using bronchoalveolar lavage fluid. The group felt that a commercially available NAA test could be more reproducible than an in-house assay and should be preferred.
The expert group recommended using a standardised NAA method from sterile sites or bronchoalveolar lavage fluid ( consensus level: 74%). No consensus was reached for NAA tests on samples other than bronchoalveolar lavage ( consensus level: 58%).
The identification of the species of Mucorales and antifungal susceptibility testing are necessary for epidemiological purposes and in patients who do not respond adequately to treatment.70Skiada A Lass-Floerl C Klimko N Ibrahim A Roilides E Petrikkos G Challenges in the diagnosis and treatment of mucormycosis.Med Mycol. 2018; 56: 93-101Google Scholar For example, infections caused by Mucorales, such as Cunninghamella bertholletiae, have been shown to respond poorly to amphotericin B.71Garey KW Pendland SL Huynh VT Bunch TH Jensen GM Pursell KZ splant patient: amphotericin lung penetration, MIC determinations, and review of the literature.Pharmacotherapy. 2001; 21: 855-860Google Scholar, 72Badali H Cañete-Gibas C McCarthy D et al.Epidemiology and antifungal susceptibilities of Mucoralean fungi in clinical samples from the United States.J Clin Microbiol. 2021; 59e0123021Google Scholar By contrast, the minimum inhibitory concentration ( MIC) of posaconazole is higher for Mucor circinelloides ( 4 μg/mL) than for other species, and mice infected with M circinelloides show poor response to posaconazole treatment.73Salas V Pastor FJ Calvo E et al.In vitro and in vivo activities of posaconazole and amphotericin B in a murine invasive infection by Mucor circinelloides: poor efficacy of posaconazole.Antimicrob Agents Chemother. 2012; 56: 2246-2250Google Scholar, 74Espinel-Ingroff A Chakrabarti A Chowdhary A et al.Multicenter evaluation of MIC distributions for epidemiologic cutoff value definition to detect amphotericin B, posaconazole, and itraconazole resistance among the most clinically relevant species of Mucorales.Antimicrob Agents Chemother. 2015; 59: 1745-1750Google Scholar, 75Dannaoui E Antifungal resistance in mucorales.Int J Antimicrob Agents. 2017; 50: 617-621Google Scholar, 76Vitale RG de Hoog GS Schwarz P et al.Antifungal susceptibility and phylogeny of opportunistic members of the order mucorales.J Clin Microbiol. 2012; 50: 66-75Google Scholar Recognising the organism also becomes relevant in cases in which differentiating septate and aseptate hyphae on morphology is difficult.70Skiada A Lass-Floerl C Klimko N Ibrahim A Roilides E Petrikkos G Challenges in the diagnosis and treatment of mucormycosis.Med Mycol. 2018; 56: 93-101Google Scholar Antifungal susceptibility testing is also valuable for dual infections ( CAPA and CAPM) as azole resistance is reported in Aspergillus fumigatus, and Aspergillus terreus is intrinsically resistant to amphotericin B.77Meijer EFJ Dofferhoff ASM Hoiting O Meis JF COVID-19-associated pulmonary aspergillosis: a prospective single-center dual case series.Mycoses. 2021; 64: 457-464Google Scholar, 78Lass-Flörl C Dietl AM Kontoyiannis DP Brock M Aspergillus terreus species complex.Clin Microbiol Rev. 2021; 34e0031120Google Scholar
The expert group recommended species identification and performing antifungal susceptibility testing for epidemiological purposes to guide the choice of antifungals, and in patients with disease progression ( consensus level: 71–74%).
It is not known whether the histopathology of CAPM is different from that of non-CAPM. Limited experience points towards little difference in the tissue reaction to the fungi.79Zurl C Hoenigl M Schulz E et al.Autopsy proven pulmonary mucormycosis due to Rhizopus microsporus in a critically ill COVID-19 patient with underlying hematological malignancy.J Fungi ( Basel). 2021; 7: 88Google Scholar Dual infections with Aspergillus and Mucorales have also been noted in pathological specimens of patients undergoing surgery for CAPM ( appendix p 8). A swollen small hyphal segment of Aspergillus might occasionally be mistaken for Mucorales. Immunohistochemistry using antibodies against Rhizopus ( and other Mucorales) could help to differentiate Aspergillus from Mucorales.80Jung J Kim MY Lee HJ et al.Comparison of computed tomographic findings in pulmonary mucormycosis and invasive pulmonary aspergillosis.Clin Microbiol Infect. 2015; 21: e11-e18Google Scholar Furthermore, identification of Mucoralean DNA by PCR ( and DNA sequencing) in fresh or formalin-fixed paraffin-embedded tissues might also be attempted in complex cases.81Jillwin J Rudramurthy SM Singh S et al.Molecular identification of pathogenic fungi in formalin-fixed and paraffin-embedded tissues.J Med Microbiol. 2021; 70: 1-8Google Scholar A diagnostic algorithm for CAPM is provided in figure 1.
CAPA is the closest differential diagnosis of CAPM because of the shared risk factors and similar clinicoradiological features.82Verweij PE Brüggemann RJM Azoulay E et al.Taskforce report on the diagnosis and clinical management of COVID-19 associated pulmonary aspergillosis.Intensive Care Med. 2021; 47: 819-834Google Scholar Dual infections of CAPA and CAPM further add to the diagnostic conundrum.36Johnson AK Ghazarian Z Cendrowski KD Persichino JG Pulmonary aspergillosis and mucormycosis in a patient with COVID-19.Med Mycol Case Rep. 2021; 32: 64-67Google Scholar Although glucocorticoids are a risk factor for both CAPA and CAPM,83Koehler P Bassetti M Chakrabarti A et al.Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance.Lancet Infect Dis. 2021; 21: e149-e162Google Scholar poorly controlled diabetes is more often associated with CAPM than with CAPA.4Hussain S Riad A Singh A et al.Global prevalence of COVID-19-associated mucormycosis ( CAM): living systematic review and meta-analysis.J Fungi ( Basel). 2021; 7: 985Google Scholar, 5Hussain S Baxi H Riad A et al.COVID-19-associated mucormycosis ( CAM): an updated evidence mapping.Int J Environ Res Public Health. 2021; 1810340Google Scholar, 26Riad A Shabaan AA Issa J et al.COVID-19-associated mucormycosis ( CAM): case-series and global analysis of mortality risk factors.J Fungi. 2021; 7: 837Google Scholar
The imaging findings of CAPM overlap with CAPA. In contrast-enhanced CT chest scans, vessel occlusion sign ( due to angioinvasion) is seen in patients with invasive pulmonary aspergillosis,84Henzler C Henzler T Buchheidt D et al.Diagnostic performance of contrast enhanced pulmonary computed tomography angiography for the detection of angioinvasive pulmonary aspergillosis in immunocompromised patients.Sci Rep. 2017; 74483Google Scholar but might also be seen in patients with pulmonary mucormycosis.41Hammer MM Madan R Hatabu H Pulmonary mucormycosis: radiologic features at presentation and over time.AJR Am J Roentgenol. 2018; 210: 742-747Google Scholar The bird's nest sign is seen in up to a third of patients with pulmonary mucormycosis, in contrast to 3% of patients with invasive pulmonary aspergillosis,80Jung J Kim MY Lee HJ et al.Comparison of computed tomographic findings in pulmonary mucormycosis and invasive pulmonary aspergillosis.Clin Microbiol Infect. 2015; 21: e11-e18Google Scholar and might help to differentiate the two invasive mould infections.38Alexander BD Lamoth F Heussel CP et al.Guidance on imaging for invasive pulmonary aspergillosis and mucormycosis: from the imaging working group for the revision and update of the consensus definitions of fungal disease from the EORTC/MSGERC.Clin Infect Dis. 2021; 72: S79-S88Google Scholar On the basis of clinical experience and the published literature, we have summarised the likelihood of diagnosing CAPA versus CAPM on encountering various radiological findings ( appendix p 3). However, in patients with radiological features highly suggestive of CAPM ( panel 2), the evaluation of CAPM might have to continue despite diagnostic evidence of CAPA ( microbiological or serological), because therapy will be dictated against dual infections ( use of antifungal agent active against both Aspergillus and Mucorales and the need for surgery). For example, in a patient with uncontrolled diabetes whose CT thorax shows RHS, the evaluation for mucormycosis should continue despite microbiological and serological evidence of aspergillosis.85Crone CG Helweg-Larsen J Steensen M Arendrup MC Helleberg M Pulmonary mucormycosis in the aftermath of critical COVID-19 in an immunocompromised patient: mind the diagnostic gap.J Mycol Med. 2021; 32101228Google Scholar
Biomarkers such as serum galactomannan have imperfect diagnostic performance for CAPA, especially in non-neutropenic individuals.86Zhou W Li H Zhang Y et al.Diagnostic value of galactomannan antigen test in serum and bronchoalveolar lavage fluid samples from patients with nonneutropenic invasive pulmonary aspergillosis.J Clin Microbiol. 2017; 55: 2153-2161Google Scholar The accuracy of bronchoalveolar lavage fluid β-D-glucan is poor ( sensitivity is 52% and specificity is 58%) for the diagnosis of invasive fungal disease.87Shi XY Liu Y Gu XM et al.Diagnostic value of ( 1 → 3) -β-D-glucan in bronchoalveolar lavage fluid for invasive fungal disease: a meta-analysis.Respir Med. 2016; 117: 48-53Google Scholar The sensitivity ( 87%) and specificity ( 81%) of bronchoalveolar lavage fluid galactomannan is acceptable in diagnosing invasive pulmonary aspergillosis.88Cao XJ Li YP Xie LM Zhang HL Qin YS Guo XG Diagnostic accuracy of bronchoalveolar lavage fluid galactomannan for invasive aspergillosis.BioMed Res Int. 2020; 20205434589Google Scholar Thus, even when performing these two tests in the bronchoalveolar lavage fluid, we can not conclusively exclude invasive pulmonary aspergillosis. However, the sensitivity improves to 94% when combining the two tests.87Shi XY Liu Y Gu XM et al.Diagnostic value of ( 1 → 3) -β-D-glucan in bronchoalveolar lavage fluid for invasive fungal disease: a meta-analysis.Respir Med. 2016; 117: 48-53Google Scholar, 88Cao XJ Li YP Xie LM Zhang HL Qin YS Guo XG Diagnostic accuracy of bronchoalveolar lavage fluid galactomannan for invasive aspergillosis.BioMed Res Int. 2020; 20205434589Google Scholar Thus, the likelihood of diagnosing CAPM is higher in a patient with negative bronchoalveolar lavage fluid β-D-glucan and galactomannan.
It is possible to encounter multiple scenarios suggestive of dual infection, which can be categorised further for research and epidemiological purposes ( appendix p 4).
The most important step in the prevention of CAPM is the judicious use of glucocorticoids and other immunosuppressants for COVID-19.89Muthu V Sehgal IS Prasad KT Agarwal R Is high-dose glucocorticoid beneficial in COVID-19?.Eur Respir J. 2021; 572100065Google Scholar Glucocorticoids should be used only in hypoxaemic individuals with COVID-19, with the dose and duration of glucocorticoids conforming to the current guidelines.90Agarwal A Rochwerg B Lamontagne F et al.A living WHO guideline on drugs for covid-19.BMJ. 2020; 370m3379Google Scholar The expert panel advised against using antifungal prophylaxis for preventing CAM or CAPM in patients with COVID-19. Instead, the emphasis was placed on optimal glycaemic control.91Mulakavalupil B Vaity C Joshi S Misra A Pandit RA Absence of case of mucormycosis ( March 2020–May 2021) under strict protocol driven management care in a COVID-19 specific tertiary care intensive care unit.Diabetes Metab Syndr. 2021; 15102169Google Scholar In patients with prolonged hypoxaemia due to COVID-19 or post-COVID-19 lung abnormalities, when a longer duration of glucocorticoids might be needed, the lowest possible dose of glucocorticoids should be used ( along with strict glycaemic control).92Dhooria S Chaudhary S Sehgal IS et al.High-dose versus low-dose prednisolone in symptomatic patients with post-COVID-19 diffuse parenchymal lung abnormalities: an open-label, randomised trial ( Acronym: COLDSTER).Eur Respir J. 2022; 592102930Google Scholar
The control of underlying risk factors is essential to improve outcomes in CAPM. For example, strict glycaemic control ( 140–180 mg/dL [ 7.8–10·0 mmol/L ]) is suggested in patients with CAPM, like in other critically ill patients.91Mulakavalupil B Vaity C Joshi S Misra A Pandit RA Absence of case of mucormycosis ( March 2020–May 2021) under strict protocol driven management care in a COVID-19 specific tertiary care intensive care unit.Diabetes Metab Syndr. 2021; 15102169Google Scholar Before initiating or withholding other immunosuppressive drugs in the transplant setting, the risk–benefit ratio must be weighed. In general, in transplant recipients receiving immunosuppression who develop CAPM, low-dose glucocorticoids could be continued to avoid graft rejection.93Meshram HS Kute VB Chauhan S et al.Mucormycosis as SARS-CoV2 sequelae in kidney transplant recipients: a single-center experience from India.Int Urol Nephrol. 2021; 18: 1-11Google Scholar
The CAPM-GG recommended surgery for all patients with potentially resectable disease ( figure 2). Extensive invasion of mediastinal structures and hilar vessels is associated with technical difficulties during surgery and poor outcome.94Saxena P Shen SH Morrissey O Gooi JH Challenges in the management of invasive pulmonary zygomycosis: the Alfred experience.ANZ J Surg. 2015; 85: 700-701Google Scholar A few patients with potentially resectable disease might not be operable due to multiple comorbidities or frailty.95Benjamin SR Narayanan D Chandy ST Gnanamuthu BR Michael JS Kodiatte TA Pulmonary mucormycosis—a case series.Indian J Thorac Cardiovasc Surg. 2021; ( published online Oct 30.) https: //doi.org/10.1007/s12055-021-01272-4Google Scholar, 96Hong HL Lee YM Kim T et al.Risk factors for mortality in patients with invasive mucormycosis.Infect Chemother. 2013; 45: 292-298Google Scholar The treatment decision for these patients needs to be individualised, ideally after a discussion involving a multidisciplinary team, consisting of thoracic surgeons, clinicians, and radiologists.Figure 2Proposed algorithm for treating CAPMShow full captionCAPM=COVID-19-associated pulmonary mucormycosis. * Treatment duration should be individualised and could be extended up to 12 weeks after complete response.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
CAPM=COVID-19-associated pulmonary mucormycosis. * Treatment duration should be individualised and could be extended up to 12 weeks after complete response.
Preoperative evaluation should include spirometry ( especially in patients due to receive a pneumonectomy or patients with chronic respiratory disease) and assessment of frailty and exercise capacity ( eg, 6 min walk test [ 6MWT ]).97Multani A Reveron-Thornton R Garvert DW Gomez CA Montoya JG Lui NS Cut it out! Thoracic surgeon's approach to pulmonary mucormycosis and the role of surgical resection in survival.Mycoses. 2019; 62: 893-907Google Scholar Spirometry might not be possible for patients with COVID-19 or patients with massive haemoptysis,98Muthu V Singh H Gorsi U Agarwal R Large pulmonary artery pseudoaneurysm in mucormycosis: successfully managed with surgery and amphotericin.BMJ Case Rep. 2021; 14e240813Google Scholar and the decision to operate must be made on the basis of surrogate measures ( ie, 6MWT and frailty assessment) and multidisciplinary team evaluation.
The optimal timing for surgery in CAPM is unknown, and there is a wide variation in practice.99Pulle MV Puri HV Asaf BB Bishnoi S Sharma S Kumar A Outcomes of early anti-fungal therapy with aggressive surgical resection in pulmonary mucormycosis.Lung India. 2021; 38: 314-320Google Scholar Although surgery should be performed as early as possible, the experts felt that the metabolic abnormalities ( eg, glycaemic control and electrolyte imbalance) should be corrected, which generally takes 1–2 weeks. Emergent surgery is warranted in patients with massive haemoptysis.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Google Scholar, 97Multani A Reveron-Thornton R Garvert DW Gomez CA Montoya JG Lui NS Cut it out! Thoracic surgeon's approach to pulmonary mucormycosis and the role of surgical resection in survival.Mycoses. 2019; 62: 893-907Google Scholar, 99Pulle MV Puri HV Asaf BB Bishnoi S Sharma S Kumar A Outcomes of early anti-fungal therapy with aggressive surgical resection in pulmonary mucormycosis.Lung India. 2021; 38: 314-320Google Scholar, 100Choi H Lee H Jeon K et al.Factors affecting surgical resection and treatment outcomes in patients with pulmonary mucormycosis.J Thorac Dis. 2019; 11: 892-900Google Scholar, 101Mills SEA Yeldandi AV Odell DD Surgical treatment of multifocal pulmonary mucormycosis.Ann Thorac Surg. 2018; 106: e93-e95Google Scholar In patients with CAPM, surgery could be delayed due to the poor health status of patients. However, it was suggested that surgery be performed soon after stabilising COVID-19 or post-COVID-19 hypoxaemia. Uncommonly, patients might show a good response following medical therapy and, consequently, might not require surgery for CAPM. These patients should be closely observed, and the underlying risk factors such as diabetes should be controlled. However, re-evaluation and surgery should be considered at the earliest sign of deterioration.
In patients with bilateral disease, surgery could be considered if the lesion in one of the lungs shows total or near-total resolution, or when there is a complication such as massive haemoptysis. Some patients might tolerate partial resection, provided the lung reserve permits surgery of both the lungs.
All patients with potentially resectable lung disease should undergo surgery ( consensus level: 95%). We recommend that surgery should be performed as soon as the metabolic derangements are corrected, generally within 1–2 weeks ( consensus level: 74%). Furthermore, in patients who show invasion of the mediastinal structures during imaging, we recommend initial medical management followed by reassessment for surgery ( consensus level: 81%). We also recommend that a multidisciplinary team evaluate all such patients before surgery ( consensus level: 100%).
All patients with proven or probable CAPM should be treated with antifungal agents that are effective against Mucorales. The expert group recommended against routinely treating patients with possible CAPM. However, delayed initiation of therapy is associated with high mortality in patients with mucormycosis.11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Google Scholar Hence, the treatment decision must be individualised, ideally after discussion by a multidisciplinary team ( ie, clinicians, radiologists, microbiologists). For example, patients with highly suggestive imaging ( eg, RHS, mycotic aneurysm and bird's nest sign), risk factors ( eg, post-COVID-19 in a patient with diabetes, with diabetic ketoacidosis, or on glucocorticoid therapy), and clinical features ( massive haemoptysis) would benefit from early therapy. The experts recommended classifying treatment in CAPM as primary and maintenance therapy.
Liposomal amphotericin B is the therapy of choice for patients with CAPM. The experts agreed on an initial dose of 5 mg/kg per day of intravenous liposomal amphotericin B as recommended by the global guidelines for mucormycosis.11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Google Scholar A higher dose ( 10 mg/kg per day) has been suggested to treat intracranial disease.11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Google Scholar, 102Soni K Das A Sharma V et al.Surgical & medical management of ROCM ( rhino-orbito-cerebral mucormycosis) epidemic in COVID-19 era and its outcomes—a tertiary care center experience.J Mycol Med. 2021; 32101238Google Scholar, 103Lanternier F Poiree S Elie C et al.Prospective pilot study of high-dose ( 10 mg/kg/day) liposomal amphotericin B ( L-AMB) for the initial treatment of mucormycosis.J Antimicrob Chemother. 2015; 70: 3116-3123Google Scholar The experts advocated against dose escalation of liposomal amphotericin B for patients with bilateral pulmonary disease or inoperable CAPM, although no consensus was reached for critically ill patients with CAPM. When liposomal amphotericin B is not available, other lipid formulations of amphotericin B could be used.10Rudramurthy SM Hoenigl M Meis JF et al.ECMM/ISHAM recommendations for clinical management of COVID-19 associated mucormycosis in low- and middle-income countries.Mycoses. 2021; 64: 1028-1037Google Scholar, 11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Google Scholar Posaconazole or isavuconazole should not be routinely used as primary therapy because there is no supporting randomised controlled trial, except in situations in which the organism is known to have a high minimum inhibitory concentration for amphotericin B ( eg, C bertholletiae). The experts agreed that triazoles might also be the primary therapy when none of the amphotericin B formulations are available.
When administering amphotericin B, serum electrolytes, renal and liver functions, and complete blood count should be closely monitored. Hypokalaemia induced by amphotericin B could be aggravated by glucocorticoids used for COVID-19. Daily electrolyte monitoring with electrolyte supplementation was proposed for hypokalaemia and hypomagnesaemia, and amphotericin B can be continued with electrolyte supplementation. The renal dysfunction associated with amphotericin B is generally reversible after discontinuing therapy. All formulations of amphotericin B have been safely used in a standard dosage, even in patients on renal replacement therapy.104Anaissie EJ Mattiuzzi GN Miller CB et al.Treatment of invasive fungal infections in renally impaired patients with amphotericin B colloidal dispersion.Antimicrob Agents Chemother. 1998; 42: 606-611Google Scholar, 105Wood JE Mahnensmith MP Mahnensmith RL Perazella MA Intradialytic administration of amphotericin B: clinical observations on efficacy and safety.Am J Med Sci. 2004; 327: 5-8Google Scholar The experts advised temporarily discontinuing amphotericin B if the serum creatinine values double from baseline and advised restarting amphotericin B once the values normalise. Another approach is to reduce the dose of amphotericin B ( from 5 mg/kg per day to 1–3 mg/kg per day) and increase the dose once the serum creatinine values return to baseline. Some patients with progressive renal dysfunction, anaphylaxis, drug non-availability, or drug intolerance might need to switch over to salvage therapy with posaconazole or isavuconazonium.
The optimal duration of primary therapy for CAPM is unclear. The experts recommended that the duration of therapy be based on response assessment rather than fixed duration ( table 2). However, most experts agreed that complete or partial response is generally achieved by 4–6 weeks of primary therapy.Table 2Response assessment criteria in COVID-19 associated pulmonary mucormycosisDefinitionSuccessComplete responseSurvival and resolution of all attributable clinical features ( symptoms and signs) of disease, and resolution of the radiological lesion ( or lesions) or persistence of only a scar or postoperative changes that can be equated with a complete radiological responsePartial responseSurvival and resolution of all attributable clinical features ( symptoms and signs) of disease, and a 25% or higher reduction in the diameter of radiological lesion ( or lesions); or radiological stabilisation ( < 25% reduction in the diameter of the lesion), and resolution of all attributable symptoms and signs of fungal diseaseFailureStable diseaseSurvival and minor or no improvement in all attributable clinical features ( symptoms and signs) of disease and radiological stabilisation ( < 25% reduction in the diameter of the lesion) Progressive diseaseWorsening clinical symptoms or signs of disease, and new sites of disease or radiological worsening of pre-existing lesions or persistent isolation of MucoralesDeathDeath due to any cause during the period of assessmentThe criteria have been adapted from the Mycoses Study Group and European Organisation for Research and Treatment of Cancer consensus criteria for response assessment in invasive mould disease.106Segal BH Herbrecht R Stevens DA et al.Defining responses to therapy and study outcomes in clinical trials of invasive fungal diseases: Mycoses Study Group and European Organization for Research and Treatment of Cancer consensus criteria.Clin Infect Dis. 2008; 47: 674-683Google Scholar Open table in a new tab
The criteria have been adapted from the Mycoses Study Group and European Organisation for Research and Treatment of Cancer consensus criteria for response assessment in invasive mould disease.106Segal BH Herbrecht R Stevens DA et al.Defining responses to therapy and study outcomes in clinical trials of invasive fungal diseases: Mycoses Study Group and European Organization for Research and Treatment of Cancer consensus criteria.Clin Infect Dis. 2008; 47: 674-683Google Scholar
We recommend liposomal amphotericin B ( 5 mg/kg per day) as the treatment of choice for CAPM ( consensus level: 100%). This dose could be escalated ( 10 mg/kg per day) in patients with intracranial involvement ( consensus level: 48%). If the liposomal formulation is unavailable, any amphotericin formulation can be used for primary therapy rather than posaconazole or isavuconazole ( consensus level: 94–100%). We do not recommend escalating the dose of amphotericin B in patients with bilateral or non-operable disease or uncontrolled risk factors ( consensus level: 85–90%).
The ideal time for response assessment using a CT scan remains unclear. Chest radiography might be performed weekly, or as clinically indicated, to detect radiological deterioration rather than improvement. Unlike in invasive pulmonary aspergillosis, improvement in pulmonary mucormycosis takes longer, particularly in patients with diabetes.103Lanternier F Poiree S Elie C et al.Prospective pilot study of high-dose ( 10 mg/kg/day) liposomal amphotericin B ( L-AMB) for the initial treatment of mucormycosis.J Antimicrob Chemother. 2015; 70: 3116-3123Google Scholar The expert group recommended performing a CT scan of the thorax at 4–6 weeks to assess treatment response.106Segal BH Herbrecht R Stevens DA et al.Defining responses to therapy and study outcomes in clinical trials of invasive fungal diseases: Mycoses Study Group and European Organization for Research and Treatment of Cancer consensus criteria.Clin Infect Dis. 2008; 47: 674-683Google Scholar The response should be categorised as complete response, partial response, stable disease, or progressive disease ( table 2). A complete or partial response is classified as a successful outcome, whereas stable or progressive disease is considered a treatment failure.106Segal BH Herbrecht R Stevens DA et al.Defining responses to therapy and study outcomes in clinical trials of invasive fungal diseases: Mycoses Study Group and European Organization for Research and Treatment of Cancer consensus criteria.Clin Infect Dis. 2008; 47: 674-683Google Scholar
Once a complete or partial response is achieved, maintenance treatment with isavuconazole or posaconazole should be initiated ( except when the organism isolated is resistant to azoles, eg, M circinelloides).107Borman AM Fraser M Patterson Z Palmer MD Johnson EM In vitro antifungal drug resistance profiles of clinically relevant members of the Mucorales ( Mucoromycota) especially with the newer triazoles.J Fungi ( Basel). 2021; 7: 271Google Scholar A clear consensus was not achieved even after three rounds of Delphi regarding the duration of treatment after attaining a complete or partial response. Although most ( two-thirds) participants in the expert group suggested at least 4–6 weeks of maintenance therapy after complete response, a few experts felt the need for a longer duration ( up to 3 months). Importantly, all of the experts agreed that the duration of maintenance treatment needs to be personalised. The factors to be considered are the predisposing conditions ( COVID-19 only vs COVID-19 with coexisting diabetes vs COVID-19 in organ transplant recipients, for whom the reversal of immune status differs), the extent of lung involvement, complete or partial surgical resection, response to initial therapy, the type of Mucorales, and coexisting pulmonary illnesses for which a delayed resolution is expected.
A delayed-release tablet of posaconazole is preferred to the suspension form.25Cornely OA Duarte RF Haider S et al.Phase 3 pharmacokinetics and safety study of a posaconazole tablet formulation in patients at risk for invasive fungal disease.J Antimicrob Chemother. 2016; 71: 718-726Google Scholar The suspension form has variable absorption and less dependable pharmacokinetics than the posaconazole tablet.108Chen L Krekels EHJ Verweij PE Buil JB Knibbe CAJ Brüggemann RJM Pharmacokinetics and pharmacodynamics of posaconazole.Drugs. 2020; 80: 671-695Google Scholar The expert group favoured posaconazole over isavuconazole due to its wider availability, reduced cost of therapy, more experience of its use by health-care professionals, and published evidence. However, therapeutic drug monitoring is recommended for patients on posaconazole therapy, and the target concentration should be more than 1 mg/L. By contrast, isavuconazole does not need therapeutic drug monitoring, might have lesser toxicity and better bioavailability than posaconazole, but has a higher cost than posaconazole.10Rudramurthy SM Hoenigl M Meis JF et al.ECMM/ISHAM recommendations for clinical management of COVID-19 associated mucormycosis in low- and middle-income countries.Mycoses. 2021; 64: 1028-1037Google Scholar, 109McCarthy MW Moriyama B Petraitiene R Walsh TJ Petraitis V Clinical pharmacokinetics and pharmacodynamics of isavuconazole.Clin Pharmacokinet. 2018; 57: 1483-1491Google Scholar, 110Zurl C Waller M Schwameis F et al.Isavuconazole treatment in a mixed patient cohort with invasive fungal infections: outcome, tolerability and clinical implications of isavuconazole plasma concentrations.J Fungi ( Basel). 2020; 6: e90Google Scholar
In patients with stable disease or partial response, surgery should be considered along with maintenance therapy with posaconazole or isavuconazole. The experts suggested the following measures in patients with progressive disease: excluding secondary infections, species identification, and antifungal susceptibility testing ( if not performed earlier). Additionally, the underlying risk factors for CAPM should be addressed. The experts reached a consensus on the following therapeutic approach in patients with progressive disease: continuing liposomal amphotericin B, or using posaconazole or isavuconazole as salvage therapy for a longer duration until a complete or partial response is achieved. The experts suggested against using a combination of antifungal agents in patients with treatment failure.111Fortun J Gioia F Cardozo C et al.Posaconazole salvage therapy: the Posifi study.Mycoses. 2019; 62: 526-533Google Scholar, 112van Burik JA Hare RS Solomon HF Corrado ML Kontoyiannis DP Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases.Clin Infect Dis. 2006; 42: e61-e65Google Scholar Despite a theoretical advantage of drug synergy,113Schwarz P Cornely OA Dannaoui E Antifungal combinations in Mucorales: a microbiological perspective.Mycoses. 2019; 62: 746-760Google Scholar there is currently no clear evidence supporting the use of a combination of antifungal drugs for the treatment of pulmonary mucormycosis.11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Google Scholar, 112van Burik JA Hare RS Solomon HF Corrado ML Kontoyiannis DP Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases.Clin Infect Dis. 2006; 42: e61-e65Google Scholar A management algorithm is provided in figure 2.
We recommend maintenance treatment with isavuconazole or posaconazole after the patient achieves a complete or partial response ( consensus: 100%). No consensus could be reached regarding the duration of treatment after the patient attains a complete or partial response. We do not recommend a combination of antifungal drugs ( posaconazole or isavuconazole with amphotericin) in patients with treatment failure ( consensus level: 89%). We recommend continuing liposomal amphotericin B or using posaconazole or isavuconazole for a longer duration until a complete or partial response is achieved, as salvage therapy in patients with treatment failure ( consensus level: 89–100%).
In the absence of high-quality data for CAPM or non-CAPM, nebulised amphotericin B was not recommended for treatment. Colony-stimulating factors ( G-CSF, GM-CSF) or neutrophil transfusions should not be routinely used in patients with CAPM.
The expert group identified the following broad areas for conducting research: incidence and epidemiology of CAPM at different geographical locations; factors contributing to the development of CAPM in patients with COVID-19; imaging findings of CAPM versus CAPA; the role of molecular diagnostics ( ie, blood, endotracheal aspirate, or sputum) in CAPM; and duration of medical therapy for CAPM and timing of surgery.
Data on CAPM are scarce. This Review is primarily based on the opinions of a small group of experts, although this group does have considerable experience and were actively managing CAPM cases during the pandemic. The opinions of this group might have inherent biases, as all the experts are from a single country. Furthermore, the experiences of the experts are derived from a population comprising patients from a single country, with possible common geographical, racial, genetic, and environmental factors. CAPM could behave differently in other parts of the world. The strengths of the decision process include obtaining anonymous responses from the experts and performing three rounds of Delphi to clarify ambiguous statements and questions. Although CAPA has been recognised as an important complication of COVID-19 in many countries, CAPM remains under-diagnosed. The absence of a biomarker for CAPM is a substantial drawback, and the true incidence of CAPM might be underestimated. The current consensus opinion therefore provides a framework to improve awareness of, identify, and manage CAPM until well conducted studies are available. The various possible categories of dual infections of CAPA and CAPM are also categorised.
In conclusion, this Review provides current knowledge on the epidemiology, risk factors, and expert guidance on defining CAPM for patient care and research. Furthermore, this Review summarises the available data on imaging, diagnostic challenges, and management issues unique to CAPM, which are likely to evolve with further research. The widespread dissemination of these guidelines could improve awareness about CAPM, and possibly research into CAPM, to meet the unmet needs in this field.
AC and RA contributed to the conceptualisation and funding acquisition. VM, AP, AK, UM, SMR, and ASB contributed to data curation. VM, RA, ANA, and SK contributed to formal analysis. RA, VM, and AC contributed to investigation and resources. AC, SK, RA, VM, AP, GMV, and RS contributed to methodology. AC, RA, and SMR contributed to project administration. SMR and VM contributed to software. ANA, AC, RG, DC, AM, and RS contributed to validation. RA, SK, and AC contributed to visualistion. VM, RA, and SK contributed to writing the original draft. All authors contributed to writing, reviewing, and editing the submitted work.
AP received honoraria and lecture fees from Gilead Sciences, Pfizer ( India), Intas Pharmaceuticals, Mylan ( India), Bharat Serum Vaccine, and Cipla India. TS received lecture fees from Mylan ( India), Cipla India, Merck Sharp & Dohme, Intas Pharmaceuticals, Pfizer ( India), and Glenmark Pharmaceuticals. All other authors declare no competing interests.
The Fungal Infection Study Forum and Academy of Pulmonary Sciences supported the Delphi process and organised the virtual discussion.
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The Lancet Global Health Commission on financing primary health care: putting people at the centre - The Lancet Global Health | The COVID-19 pandemic has brought the need for well-functioning primary health care ( PHC) into sharp focus. PHC is the best platform for providing basic health interventions ( including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage.
PHC was famously set as a global priority in the 1978 Alma-Ata Declaration. More recently, the 2018 Astana Declaration on PHC made a similar call for universal coverage of basic health care across the life cycle, as well as essential public health functions, community engagement, and a multisectoral approach to health. Yet in most low-income and middle-income countries ( LMICs), PHC is not delivering on the promises of these declarations. In many places across the globe, PHC does not meet the needs of the people—including both users and providers—who should be at its centre. Public funding for PHC is insufficient, access to PHC services remains inequitable, and patients often have to pay out of pocket to use them. A vicious cycle has undermined PHC: underfunded services are unreliable, of poor quality, and not accountable to users. Therefore, many people bypass primary health-care facilities to seek out higher-level specialist care. This action deprives PHC of funding, and the lack of resources further exacerbates the problems that have driven patients elsewhere.
Health systems are fuelled by their financing arrangements. These arrangements include the amount of funding the system receives, the ways funds are moved through the system to frontline providers, and the incentives created by the mechanisms used to pay providers. Establishing the right financing arrangements is one crucially important way to support the development of people-centred PHC. Improving financing arrangements can drive improvements in how PHC is delivered and equip the system to respond effectively to evolving population health needs. Thus attention should be paid simultaneously to both financing and service delivery arrangements.
In this report, the Lancet Global Health Commission on financing PHC argues that all countries need to both invest more and invest better in PHC by designing their health financing arrangements—mobilising additional pooled public funding, allocating and protecting sufficient funds for PHC, and incentivising providers to maintain the health of the populations they serve—in ways that place people at the centre and by addressing inequities first.
Answering the question of how to make these changes goes far beyond technical considerations. Fundamentally shifting a health system's priorities—away from specialist-based and hospital-based services and towards PHC—involves political choices and creates numerous political challenges. Successfully reorienting a system towards PHC requires savvy political leadership and long-term commitment, as well as proactive, adaptable strategies to engage with stakeholders at all levels that account for the social and economic contexts. Therefore, this report addresses both technical and political economy considerations involved in strengthening financing for PHC.
Despite broad recognition of the importance of PHC, there is no global consensus on what exactly constitutes PHC. This makes it challenging to measure and report on levels of expenditure on PHC. In this Commission we define PHC as a service delivery system or platform, together with the human and other resources needed for it to function effectively. We found that LMICs spend far too little on PHC to provide equitable access to essential services and that much of the ( significant) variation in PHC spending levels across countries is explained by national income levels, although there is variation in the amount of government resources allocated to PHC at any given level of economic development. Furthermore, at every level of PHC spending, there is substantial variation in performance, suggesting that we need to spend better as well as spending more.
In this Commission, we analysed provider payment methods and found that the sources of PHC expenditure remain fragmented and overly reliant on out-of-pocket payments. Population-based provider payment mechanisms, such as capitation, should be the cornerstone of financing for people-centred PHC. However, these mechanisms are rare in LMICs, where input-based budgets are standard practice. Furthermore, many features of primary health-care organisation that are necessary for population-based payment strategies ( such as empanelment, registration, and gatekeeping) are absent in LMICs.
Redressing these limitations to improving financing PHC is urgent, as new challenges continue to arise. As in other parts of the health sector, PHC will continue to become more integrated, digitally-driven, and pluralistic; therefore, PHC financing arrangements also need to evolve to support, drive, and guide these changes to better meet human needs.
The Commission takes the position that progressive universalism should drive every aspect of PHC. That means putting the rights and needs of the poorest and most vulnerable segments of a population first. This requires unwavering ethical, political, and technical commitment and focus. Together with this overarching principle, we identified four key attributes of people-centred financing arrangements that support PHC.
( 1) Public resources should provide the core of primary health-care funding. Revenue-raising mechanisms should be defined based on the ability to pay and be progressive. Out-of-pocket payments must be reduced to levels where they are no longer a financial barrier to accessing needed care, impoverish households, or push households deeper into poverty. In most LMICs, this level of public funding for PHC can only be generated through increased allocations to PHC from general tax revenue, and therefore requires an expansion of countries ' taxation capacities. In low-income countries, more development assistance will be needed to expand the resource envelope for PHC. ( 2) Pooled funds should be used to allow all people to receive PHC that is provided free at the point of use. Only once universal coverage with PHC is achieved should pooled resources be extended to cover other entitlements. In this way, PHC can help fulfil the promise of universal health coverage. ( 3) Resources for PHC should be allocated equitably ( across levels of service delivery and geographic areas) and protected as they flow through the system to frontline providers. Countries should deploy a set of strategic resource allocation tools ( including a needs-based per-capita resource allocation formula and effective public financial management tools) to match primary health-care funding with population needs and ensure these resources reach the frontline, and prioritise the poorest and most vulnerable people. ( 4) Payment mechanisms for primary health-care providers should support allocation of resources based on people's health needs, create incentive environments that promote PHC that is people-centred, and foster continuity and quality of care. To achieve these goals, a so-called blended provider payment mechanism with capitation at its core is the best approach to paying for PHC. Capitation should form the core of the primary health-care financing system because it directly links the population with services. Combining capitation with other payment mechanisms, such as performance-based payments for specific activities, enables additional objectives to be achieved.
Each country is at a different point along its path towards the goal of effective financing for PHC. The four attributes outlined both represent goals and present a guide for working towards those goals. This Commission recognises that, depending on the context, the evolution of an effective primary health-care financing system in some countries might occur through incremental changes, whereas others can implement comprehensive reforms. Improving PHC financing can occur in response to bottom-up advocacy, top-down policy or, most likely, through a combination of grassroots and technocratic approaches. Political, social, and economic factors are therefore as important as technical design elements when it comes to enacting efficient and equitable primary health-care financing reform. Changing the ways in which PHC is financed requires support from a wide range of stakeholders, and deliberate political strategies, to determine and then stay the course. The change also requires good information about PHC resource levels and flows so that this reorientation can be effectively managed and monitored.
In this Commission, we provide five recommendations.
( 1) People-centred financing arrangements for PHC should have public resources provide the bulk of primary health-care funding; pooled funds cover primary-health care, enabling all people to receive PHC that is provided free at the point of service use; resources for PHC are allocated equitably across levels of service delivery and geographic areas, and are protected so that sufficient resources reach frontline primary health-care service providers and patients; and primary health-care provider payment mechanisms support the allocation of resources based on people's health needs, create incentive environments that promote PHC that is people centred, foster continuity and quality of care, and remain flexible enough to support rapidly changing service delivery models. ( 2) Spending more and spending better on PHC requires a whole-of-government approach involving all ministries whose remit interacts with health and requires the support of civil society. Key actors and stakeholders should be involved in designing and implementing financing arrangements for PHC that are people-centred. Although the specifics will vary depending on the national context, there are important roles and responsibilities for ministries of health, ministries of finance, local government authorities, communities and civil society groups, health-care providers and organisations, donors, and technical agencies. ( 3) Each country should plot out a strategic pathway towards people-centred financing for PHC that reflects the attributes outlined above, including investments in supporting basic health system functions. Technical strategies should be underpinned from the outset by analysis of the political economy. ( 4) Global technical agencies should reform the way primary health-care expenditure data are collected, classified, and reported to enable longitudinal and cross-country analyses of achievement of key primary health-care financing goals. ( 5) Academic researchers, technical experts, and policy makers, among others, should pursue a robust research agenda on financing arrangements for PHC that place people at the centre to support achievement of key primary health-care financing goals.
Primary health care ( PHC) is a key component of all high-performing health systems,1Organisation for Economic Co-operation and DevelopmentRealising the Potential of PHC. Organisation for Economic Co-operation and Development Publishing, Paris2020Google Scholar an essential foundation for universal health coverage ( UHC), and a prerequisite for meeting the Sustainable Development Goals. It is a pathway to achieving good health at low cost2Balabanova D Mills A Conteh L et al.Good Health at low cost 25 years on: lessons for the future of health systems strengthening.Lancet. 2013; 381: 2118-2133Google Scholar by providing essential and cost-effective health interventions, including health promotion; maternal, newborn, and child health care; immunisations; and treatment for common illnesses across the life course. As the global burden of non-communicable diseases increases, PHC is emerging as the locus of both prevention and the coordination of life-long management of chronic conditions. PHC also has an important role in providing essential public health functions, including responding to epidemic diseases such as the COVID-19 pandemic.
When successfully delivered, PHC serves as a key vehicle for fulfilling governmental and societal commitments. For example, primary health-care expansion improves equity when its services reach vulnerable segments of the population.3Starfield B Shi L Macinko J Contribution of primary care to health systems and health.The Milbank Quarterly. 2005; 83: 457-502Google Scholar Because primary health-care services are provided where people live and work,4Sacks E Schleiff M Were M Chowdhury AM Perry HB Communities, universal health coverage and primary health care.Bull World Health Organ. 2020; 98: 773-780Google Scholar and because PHC focuses on population health, it can address many determinants of health that underpin various sources of vulnerability.5WHOClosing the gap in a generation: health equity through action on the social determinants of health—final report of the Commission on Social Determinants of Heath. WHO, Geneva2008Google Scholar PHC can protect households ' financial wellbeing by fostering good health and reducing the risks of disease among breadwinners, caregivers, and other family members, and by averting the need for expensive secondary and tertiary health care.6WHOUNICEFA vision for PHC in the 21st century: towards universal health coverage and the Sustainable Development Goals. WHO, Geneva2018Google Scholar In fragile states and conflict-affected settings, primary health-care services can help build trust in the health system—and in the government it represents.7Organisation for Economic Co-operation and DevelopmentService delivery in fragile situations.OECD J Dev. 2009; 9: 13Google Scholar
A convincing economic case for PHC has been made repeatedly. Most of the available evidence comes from high-income countries. In these contexts, it has been shown that by providing key services at the lowest appropriate level of the health system, PHC can decrease the need for unnecessary hospital admissions, prevent avoidable readmissions, and limit inappropriate use of emergency departments.8WHOBuilding the economic case for PHC: a scoping review. WHO, Geneva2018Google Scholar In low-income to middle-income countries ( LMICs), an expanding body of evidence shows the cost-effectiveness of many interventions that are typically delivered through PHC. Indeed, a 2018 analysis classified 198 ( 91%) of 218 essential UHC interventions as PHC9Watkins DA Yamey G Schäferhoff M et al.Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in Health.Lancet. 2018; 392: 143-160Google Scholar and another report estimated that up to 75% of the projected health gains from the SDGs could be achieved through PHC.10Stenberg K Hanssen O Bertram M et al.Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study.Lancet Glob Health. 2019; 7: e1500-e1510Google Scholar Expanding a core set of integrated interventions for women's and children's health ( narrower than PHC) is calculated to generate economic and health benefits in low-income countries valued at 7·2 times more than the costs; the value increases to 11·3 in lower-middle-income countries.11Stenberg K Axelson H Sheehan P et al.Advancing social and economic development by investing in women's and children's health: a new global investment Framework.Lancet. 2014; 383: 133-154Google Scholar A study of 67 LMICs projected that investing in PHC over the period from 2020 to 2030 would avert up to 64 million deaths.10Stenberg K Hanssen O Bertram M et al.Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study.Lancet Glob Health. 2019; 7: e1500-e1510Google Scholar
There is also a strong case for public investments in common goods for health, including public goods12Gaudin S Smith PC Soucat A Yazbeck AS Common goods for health: economic rationale and tools for prioritization.Health Syst Reform. 2019; 5: 280-292Google Scholar ( which, in the economic sense, are services and functions that are both non-rival and non-exclusive), and in functions that generate strong positive externalities. These goods, which include the essential public health functions in PHC, require public funding as they are otherwise subject to market failure.
Yet despite its fundamental importance and incredible promise, PHC is not doing well in many countries, especially LMICs. The global community first proclaimed its commitment to multisectoral and integrated PHC in the 1978 Alma-Ata Declaration. However, this commitment was quickly derailed, with funding and technical support flowing instead into vertical and disease-specific programmes.13Walraven G The 2018 Astana Declaration on Primary Health Care, is it useful?.J Glob Health. 2019; 9010313Google Scholar Despite periodic attempts to refocus on PHC, vertical programmes and hospital-based and specialist-based care models have regularly been prioritised over PHC. Funding for PHC is generally insufficient, access to primary health-care services remains inequitable, services are of inadequate quality, and patients often have to make out-of-pocket payments to use them. Health-care worker shortages persist, particularly in rural areas where the need is often greatest, and in many countries supplies of medicines, equipment, and other necessary commodities are grossly inadequate.6WHOUNICEFA vision for PHC in the 21st century: towards universal health coverage and the Sustainable Development Goals. WHO, Geneva2018Google Scholar
This situation reinforces a cycle of neglect of PHC: when primary health-care services are unreliable, of poor quality, and not accountable to system users, it leads to poor uptake and low levels of trust in community-level health care. Users choose to bypass primary health-care services, which then receive even fewer resources. To successfully provide PHC at community level, national and local health-care systems need to be reimagined and restructured, beginning with placing the needs and preferences of people ( including the intended users and providers) at the centre of the system design.6WHOUNICEFA vision for PHC in the 21st century: towards universal health coverage and the Sustainable Development Goals. WHO, Geneva2018Google Scholar, 14WHOIntegrating health services. World Health Organization, Geneva2018Google Scholar
Health financing arrangements provide the fuel for health systems: they establish the amount of resourcing available and the way in which risks are shared among those who are ill and those who are well, the ways that funds flow through the system to frontline providers, and the payment systems that create incentives for providers. Together, these arrangements shape the equity, effectiveness, and efficiency of PHC.
This report focuses on how to get the financing arrangements right to serve and fuel effective, efficient, and equitable PHC service delivery. As will be discussed throughout the report, establishing the right financing arrangements for effective and equitable PHC can both support and drive other necessary transformations. This Commission contends that health financing arrangements for PHC—how to mobilise sufficient resources to support PHC objectives, how to ensure that resources reach frontline providers in ways that align with PHC objectives, and how to design financial incentives that encourage the delivery of, and access to, high-quality, equitable, integrated and efficient PHC—should be centred on people, and focused on equity. Panel 1 presents descriptions of two key terms that are used throughout the report: health financing functions and health financing arrangements.Panel 1Health financing functions and arrangementsThree core health financing functions are mentioned throughout the report: •Mobilisation of funds: the collection of revenue ( from taxes, insurance contributions, user fees, donations, or other means) that is used to pay for delivery of health services. Resource mobilisation is addressed in detail in section 3.•Pooling: accumulating prepaid funds ( such as social security contributions, taxes, or health insurance premiums) to pay for health services for a group of people. Pooling is addressed in section 3.•Purchasing: the mechanisms by which mobilised and pooled funds are transferred to providers who deliver health services. Purchasing involves three elements: specifying what services will be purchased ( often called the benefit package), identifying which providers are eligible to provide these services, and defining the set of arrangements through which providers are contracted to provide the services. How providers are paid to provide primary health care ( PHC) is the focus of section 5.We refer in the report to a number of different ways of paying PHC providers: •A line-item budget is when providers are given prospectively a fixed amount of funds to cover specific line items, such as medicines and utilities, for a period ( usually a year).•A fee-for-service payment is when providers are reimbursed for each individual service provided.•A capitation payment is when providers are given a fixed per-person payment, determined and paid in advance, to deliver a defined set of services to each enrolled individual for a specified period of time.•A pay-for-performance system is when providers are given bonus payments ( or penalties) for achieving service coverage or quality targets.We use the broader term health financing arrangements to refer to both the core health financing functions and the ways in which they are organised and interact. These arrangements include the public financial management processes through which resources flow to frontline providers. Throughout the report we pay particular attention to:15Andrews M Cangiano M Cole N De Renzio P Krause P Seligmann R This is PFM. CID Working Paper no 2852014.https: //www.hks.harvard.edu/centers/cid/publications/faculty-working-papers/pfmDate accessed: July 20, 2021Google Scholar •Budget formulation: the process of determining, soliciting, and securing sufficient public funding for PHC and the health system overall.•Resource allocation: the process of assigning available resources to specific uses ( in this case, to PHC).•Budget execution: how the funds budgeted for services flow through the public system to providers.
Three core health financing functions are mentioned throughout the report: •Mobilisation of funds: the collection of revenue ( from taxes, insurance contributions, user fees, donations, or other means) that is used to pay for delivery of health services. Resource mobilisation is addressed in detail in section 3.•Pooling: accumulating prepaid funds ( such as social security contributions, taxes, or health insurance premiums) to pay for health services for a group of people. Pooling is addressed in section 3.•Purchasing: the mechanisms by which mobilised and pooled funds are transferred to providers who deliver health services. Purchasing involves three elements: specifying what services will be purchased ( often called the benefit package), identifying which providers are eligible to provide these services, and defining the set of arrangements through which providers are contracted to provide the services. How providers are paid to provide primary health care ( PHC) is the focus of section 5.
We refer in the report to a number of different ways of paying PHC providers: •A line-item budget is when providers are given prospectively a fixed amount of funds to cover specific line items, such as medicines and utilities, for a period ( usually a year).•A fee-for-service payment is when providers are reimbursed for each individual service provided.•A capitation payment is when providers are given a fixed per-person payment, determined and paid in advance, to deliver a defined set of services to each enrolled individual for a specified period of time.•A pay-for-performance system is when providers are given bonus payments ( or penalties) for achieving service coverage or quality targets.
We use the broader term health financing arrangements to refer to both the core health financing functions and the ways in which they are organised and interact. These arrangements include the public financial management processes through which resources flow to frontline providers. Throughout the report we pay particular attention to:15Andrews M Cangiano M Cole N De Renzio P Krause P Seligmann R This is PFM. CID Working Paper no 2852014.https: //www.hks.harvard.edu/centers/cid/publications/faculty-working-papers/pfmDate accessed: July 20, 2021Google Scholar •Budget formulation: the process of determining, soliciting, and securing sufficient public funding for PHC and the health system overall.•Resource allocation: the process of assigning available resources to specific uses ( in this case, to PHC).•Budget execution: how the funds budgeted for services flow through the public system to providers.
In this Commission, we aimed to present new evidence on levels and patterns of global expenditure on PHC ( throughout the report, the terms expenditure and spending are used interchangeably), including describing how PHC is currently organised and paid for; analyse key technical and political economy challenges faced in financing PHC; identify areas of proven or promising practices that effectively support PHC across the key health financing functions; and identify actionable policies to support LMICs in raising, allocating, and channelling resources in support of the delivery of effective, efficient, and equitable PHC that is people centred. Section 1 provides a general introduction to PHC policy and challenges. It then characterises global and national challenges, as well as opportunities, related to financing PHC. Section 2 describes the current financing landscape for PHC, detailing existing patterns of expenditure, provider payment, and related organisational features. Section 3 elaborates on mobilising sufficient resources for health through progressive means and then pooling resources to enable cross-subsidisation between those who are ill and those who are well. Section 4 focuses on how to ensure that resources mobilised for health are allocated to PHC, and emphasises the importance of engaging with the multiple budget tools available to Ministries of Health to ensure that resources reach frontline providers. Section 5 highlights the importance of structuring incentives for PHC providers so that they are motivated to provide PHC that is people centred, and proposes a strategic pathway of steps that countries can take to establish appropriate incentives. Section 6 describes the importance of, and notes strategies for, addressing the political economy of financing PHC. Finally, section 7 presents a synthesis of the vision for people-centred financing arrangements for PHC, summarises possible pathways for working towards this vision, and provides recommendations and proposes actions for different stakeholders committed to supporting LMICs to spend more—and to spend better—on PHC. It is the Commission's hope that this report will serve as a resource to policy makers around the world who are committed to this crucial endeavour.
We prepared this Commission through an extensive process of study and debate on good and promising practices in financing PHC. The 22 expert members, representing 19 nationalities, have amongst them experience working in national governments, technical agencies, bilateral and multilateral donors, universities, and independent think tanks. Assisted by a technical team based at the London School of Hygiene & Tropical Medicine, London, Commissioners drew on the following sources of evidence: case studies prepared by national consultants on innovations in PHC financing in seven LMICs ( Brazil, Chile, China, Ethiopia, Ghana, India, and Philippines) and three high-income countries ( Estonia, Finland, and New Zealand); a compilation of Organisation for Economic Co-operation and Development ( OECD) and WHO health expenditure data to conduct expenditure analysis; a new survey of PHC organisation and provider payment in LMICs; literature reviews, including systematic and scoping reviews, of existing knowledge on financing PHC; and an expert roundtable on digital technologies and PHC financing. Additional publications based on these products from the Commission are available on the Commission's website.
In different contexts, PHC has been operationalised in different ways: as an approach to the delivery of health care that reorients the system away from hospitals and specialist care to practitioners working at community-level outpatient facilities; as a coordination mechanism which links primary care, community care, specialised care, wider public health interventions, and long-term care services; 16WHOThe World Health Report 2008: primary health care now more than ever. World Health Organization, Geneva2008Google Scholar as a package of health services, often defined using cost-effectiveness as a primary criterion; as a service delivery level or platform, together with the human and other resources needed for it to function effectively; or as a system which combines a platform, a service package, and an approach that emphasises an orientation to meeting the needs of the population.
For the purposes of the Commission's health financing analyses, we found it necessary to link service delivery arrangements and orientations of PHC with the way resources are directed through the financing system to reach frontline providers. Resources typically flow to service delivery platforms. For this reason, PHC as a platform is our favoured operational definition of PHC. It typically includes both community-level and first-level health care. While it is true that some PHC services might be provided in hospital outpatient departments, it is the contention of this Commission that, over time, countries should aim to shift most PHC services out of hospitals to the appropriate community-level or first-level platforms where they can be delivered cost-effectively.
PHC is being transformed by new technologies that have the potential to overcome persistent challenges and radically change how people engage with health services. For example, digital technologies are streamlining procurement of commodities, improving supply chains, supporting health-care providers ' adherence to clinical guidelines, and enabling tracking of patients who would otherwise be lost to follow-up.17WHOWHO guideline: recommendations on digital interventions for health system strengthening. World Health Organization, Geneva2019Google Scholar, 18Health Data CollaborativeKnowledge Hub.https: //www.healthdatacollaborative.org/knowledge-hub/Date: 2021Date accessed: June 4, 2021Google Scholar New mobile and telemedicine technologies are helping patients to remotely access health information, medical advice, and their own health data. These technologies might help patients and their families to take greater responsibility for their own health and enable new, more horizontal relationships between patients and providers. Similarly, opportunities to pay insurance premiums digitally, such as via mobile phones, may help to mobilise additional financing for health. Technology-driven transformations bring some risks, including increasing health inequalities and fragmenting financing and delivery of care. However, they also offer avenues for making PHC more convenient, accessible, affordable, and high quality.
PHC will continue to evolve. For this evolution to fulfil the potential of PHC, health-care providers must expand their areas of focus and develop new skills, and health systems must develop new ways of delivering services across the life course, including incorporating preventive and supportive services. Innovations such as new digital and telehealth platforms must be deployed to support individuals and their families to manage their own health. Governments and communities must recognise and foster the role of PHC in essential public health functions, and PHC must engage with individuals and the wider community to co-produce forms of delivery that will meet people's needs. Appropriate use of technology will be key to support those delivering and those using services—eg, enabling task shifting between different cadres of health workers and delivering care that is flexible and closer to people's homes.
The COVID-19 pandemic has brought the need for PHC that is well financed into sharp focus in several ways: •It underscores the relationship between health and the economy. In particular, it has highlighted that failing to invest in health, including PHC, can have dramatic economic consequences.•Countries with stronger PHC systems were able to respond faster and more effectively to the pandemic.19Kraef C Juma P Kallestrup P Mucumbitsi J Ramaiya K Yonga G The COVID-19 pandemic and non-communicable diseases-a wake-up call for primary health care system strengthening in Sub-Saharan Africa.J Prim Care Community Health. 2020; 11 ( 2150132720946948): 1-3Google Scholar, 20Haldane V De Foo C Abdalla SM et al.Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries.Nat Med. 2021; 27: 96-180Google Scholar, 21Sagan A Webb E Assopardi-Muscat N Mata Idl McKee M Figueras J Health systems resilience during COVID-19: lessons for building back better. WHO Regional Office for Europe, Copenhagen2021Google Scholar For example, Japan, Vietnam, and South Korea were better prepared to carry out COVID-19 surveillance because they were able to capitalise on existing public health capacity for contact tracing.22Roy H Asian-inspired contact tracing strategy backed by Canadians: poll.https: //www.asiapacific.ca/publication/asian-inspired-contact-tracing-strategy-backed-canadiansDate: 2020Date accessed: July 20, 2021Google Scholar Close partnerships between multidisciplinary PHC providers and local governments allowed rapid responses by reassigning roles while still maintaining other public health services, as seen in France23André F Kergadallan M-L Zheleznyakov E France: community partnership in multidisciplinary PHC. WHO Regional Office for Europe, Copenhagen2021Google Scholar and Catalonia, Spain.24Martí T Peris A Cerezo J Spain: accelerating multidisciplinary teamwork to address emerging primary care needs in three Spanish regions. WHO Regional Office for Europe, Copenhagen2021Google Scholar This shows that PHC systems provide a foundation for effective management of health crises.•The PHC system is a good platform for public health measures to control infectious diseases. The pandemic brought renewed attention to the vital importance of common goods for health,25Yazbeck AS Soucat A When both markets and governments fail health.Health Syst Reform. 2019; 5: 268-279Google Scholar including the essential public health functions that are a component of PHC. Essential public health functions include surveillance systems, test-and-trace systems, quarantine functions, and vaccination.•Going forward, COVID-19 can only be overcome through action at the PHC level. For example, COVID-19 vaccinations will be provided through PHC platforms as provision shifts from a vertical campaign mode to a routine service. Management of mild-to-moderate illnesses related to COVID-19 will also be through PHC.•The COVID-19 pandemic has accelerated service delivery changes that were already underway. In particular, health care has rapidly adjusted to incorporate remote consultations, ramped-up support for home care, task shifting to lower-level cadres and structures, and expanded digital monitoring of health status, among others.•Above all, by highlighting the structural inequalities that exist within and across countries, the COVID-19 pandemic has emphasised the need to work for equity, solidarity, and social justice for all—these principles are central to the PHC approach.
Many of these lessons were highlighted in previous health emergencies, such as the 2014 Ebola outbreak in West Africa. However, the global scale of COVID-19, with its accompanying global and national responses, have conclusively shown that health issues can be made a top priority and that rapid changes to health systems and financing are possible. Governments and international funders alike created new flexibility in health financing arrangements, including rapid budget reallocations, mobilisation of new funds, and use of flexible purchasing arrangements. Some of these new arrangements should be retained and expanded. However, they have also exposed new areas of financial risk and vulnerability, as well as highlighting the need to continually focus on transparency and accountability.26Rahim F Allen R Barroy H Gores L Kutzin J COVID-19 funds in response to the pandemic. International Monetary Fund, Washington, DC, WA2020Google Scholar
COVID-19 has shown that the need for well-financed, well-functioning PHC has never been greater. Yet many aspects of the pandemic response have instead led to a greater concentration of resources on hospital care, vaccines, and other so-called silver-bullet approaches27The LancetThe ACT accelerator: heading in the right direction?.Lancet. 2021; 3971419Google Scholar, 28Hipgrave DB Kampo A Pearson L Health systems in the ACT-A.Lancet. 2021; 397: 1181-1182Google Scholar instead of prioritising basic public health interventions such as test-and-trace, disease surveillance, and population-based preventive measures.
This presents real risks to PHC financing and delivery. The financing requirements of the response to COVID-19 ( both by the health system and in the economic response) have placed unprecedented pressure on government budgets, while spending capacity has decreased due to declines in revenue and borrowing.29Kurowski C Evans DB Tandon A et al.From Double Shock to Double Recovery. World Bank, Washington, DC, WA2021Google Scholar For example, the immediate financing needs for additional funding for COVID-19 prevention, treatment and surveillance in sub-Saharan African countries were estimated at about 3% of gross domestic product ( GDP), or US $ 53 billion.30Schneider P Pivodic F Yoo KJ How much health financing does Sub-Saharan Africa need to fight COVID-19 ( coronavirus)?.https: //blogs.worldbank.org/health/how-much-health-financing-does-sub-saharan-africa-need-fight-covid-19-coronavirusDate: 2020Date accessed: June 10, 2021Google Scholar At the same time, the International Monetary Fund estimated that economies around the world contracted in per-capita terms by an average 5·9% in 2020 as a result of COVID-19,31International Monetary FundWorld economic outlook: managing divergent recoveries ( April 2021). International Monetary Fund, Washington, DC2021Google Scholar driving an untold number of households into poverty and reducing their ability to pay for health care.
Spending on routine health services has fallen in many countries32WHORole of primary care in the COVID-19 response. WHO Regional Office for the Western Pacific, Manila2020Google Scholar and generating more public resources for PHC will be challenging under conditions of fiscal restraint. In 90% of 105 countries surveyed by WHO, the pandemic badly disrupted many essential services that were not directly related to COVID-19, particularly mental health and reproductive, maternal, neonatal and child health care.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar Among 22 low-income countries, ten ( 45%) reported disruptions in at least 75% of essential services—this represents far more disruption than was reported in LMICs ( 30%) and upper-middle and high-income countries ( 8%).34Mathauer I Dkhimi F Townsend M Adjustments in health purchasing as part of the Covid-19 health response: results of a short survey and lessons for the future.https: //p4h.world/en/blog-covid-19-and-health-purchasing-responseDate: 2020Date accessed: September 1, 2021Google Scholar In the Democratic Republic of the Congo, for example, by October, 2020, up to 33% of the health budget had been redirected to the COVID-19 emergency response.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar Detailed accounts of the effect of COVID-19 on health financing in two other countries in sub-Saharan Africa, Sierra Leone, and South Africa, can be found in the appendix ( p 2).
The COVID-19 pandemic has thus shifted the landscape of possibilities for financing people-centred PHC in particular and health more broadly. Although it generated some new opportunities, it also created vast new challenges—and provided a glimpse of the potential havoc that future crises ( health and otherwise) can create, and the consequences of not prioritising equity.35Permanand G Kirkby V McKee M Take action at all levels of societies to fix the fractures that left so many people vulnerable to the pandemic.in: McKee M A review of the evidence: drawing the light from the pandemic. European Obervatory on Health Systems and Policies, Brussels2021Google Scholar Health financing systems need to be resilient to allow the surge capacity needed to respond to shocks while maintaining access to essential services.
To examine and operationalise financing arrangements for PHC requires clarity on what services are being financed. The PHC package can be conceptualised at three levels. At the highest level, each government and national health system must articulate its own vision for comprehensive PHC that addresses its population health needs. Fulfilling a stated vision requires drawing on resources from both public and private sources. The Alma-Ata Declaration's vision of PHC also encompasses contributions from other sectors to address social determinants of health. In this report we focus on choices made within the health budget but recognise the need to identify mechanisms for securing contributions from outside the health sector, including education, water, and sanitation. At the benefit package level, each government and health system must identify which services it can afford to provide either for free or with partial coverage. In many low-income settings, external funds will be needed to augment government financing. At the provider payment level, each health system must determine which services it will pay providers for, at what level of payment, and via which provider payment mechanism ( see section 5). Vertical programmes that provide some PHC services might be excluded from this payment system.
The specific PHC package that is financed and delivered in any particular setting will be determined by a country's ( or region's) fiscal capacity, population health needs, and political decisions about priorities. It must include both population-based essential public health functions and personal health services. Cost-effectiveness criteria should inform these choices, but a pragmatic approach is needed when combining services at an operational, or service delivery platform, level.
Directing resources to certain levels, structures, and providers makes it possible for them to function—and it also strengthens them so they can continue pulling and absorbing resources for appropriate and effective care. Conversely, inappropriate health financing arrangements can constrain effective care, and drive users to seek services that should be offered as PHC from higher levels of the system or from unregulated providers.
Getting financing functions right is important. But numerous countries ' experiences have shown that PHC financing reforms work best when the organsation of PHC delivery is improved at the same time. This might be done by, for example, creating new cadres of health worker, or by incentivising multidisciplinary team approaches. Organisational reforms both enable the absorption of additional resources and make PHC more people centred. We therefore argue that countries need to address financing levels of PHC, financing arrangements, and delivery structures at the same time.
Designing financing arrangements is more than just a technical challenge—it also involves choices that are inherently political, in the broad sense of the term. Political, socioeconomic, and cultural conditions are part of the context in which PHC financing reforms take place and are integral to whether and how reform occurs.
Increasing the allocation of resources to health might require taking resources away from other sectors. It might also necessitate changing the roles of hospitals so they are more supportive of PHC and share responsibility for population health. Strengthening financing arrangements for PHC to better reach frontline providers and communities should mean that as resources increase, the relative distribution of resources and power will favour PHC providers compared to hospitals and specialists to ensure improvements in PHC services. Such shifts are complex because they run counter to political pressures that often favour investing in readily visible improvements, such as building facilities and reducing hospital waiting times. Whether changes are instituted as top-down radical changes or via bottom-up incremental modifications, they require shifts in power and influence at all levels.
In all cases, leaders pushing to change PHC financing must attend to the political economy of PHC financing reform ( including making the political case for change and building the coalitions to enact it). Political economy considerations are woven throughout the report, and section 6 specifically addresses political economy analysis for PHC financing reform.
Financing is only one, albeit an important, element of well-functioning health systems. It strongly influences, and is influenced by, other key health system building blocks. Having these other building blocks in place is crucial. These include governance arrangements that support delivery of people-centred PHC; a health workforce that is trained and supported to provide high-quality care; data, monitoring, evaluation and learning systems to capture and disseminate accurate health and spending information; functioning procurement and distribution supply chains for medicines and other commodities; and public finance management systems supporting every aspect of financing and delivery.
The Commission has not differentiated between PHC and community health—an area that of late attracts substantial donor funding, particularly for the deployment of community health workers.36Leydon N Kureshy N Dini H-S Nefdt R Country-led institutionalisation of community health within primary health care: reflections from a global partnership.J Glob Health. 2021; 1103037Google Scholar Indeed, community health systems can be considered an advanced form of PHC implementation, where care takes place in the communities where people live and work. These platforms also present additional opportunities for deployment of new technologies. Although community health is arguably more focused on accountability and health service delivery in the context of the community ( however defined), it still depends on trained staff, supplies, infrastructure, administrative processes, and integration with higher levels of care. Community health can not exist outside the systems underpinning PHC, and must ultimately be financed on budget through the same mechanisms recommended elsewhere in this Commission. Although some governments or donor-funded programmes might separate community health activities in the context of PHC,36Leydon N Kureshy N Dini H-S Nefdt R Country-led institutionalisation of community health within primary health care: reflections from a global partnership.J Glob Health. 2021; 1103037Google Scholar others will integrate community health workers with their clinical personnel. What is most important is recognising the shared goal of universal access to primary care services and essential public health functions also prioritised by this Commission.
A key financing policy choice is whether and how to pay community health workers. Securing sustainable financing for community health worker programmes can be a challenge, particularly as in many countries these rely on external funding.37Zulu JM Perry HB Community health workers at the dawn of a new era.Health Res Policy Syst. 2021; 19: 130Google Scholar Debates about paying community health workers typically focus on the trade-offs between reliance on volunteerism underpinned by intrinsic motivation of volunteers and the need to recognise and remunerate work fairly ( and in doing so, addressing gender disparities, as most of the community health worker workforce is female).38Hermann K Van Damme W Pariyo GW et al.Community health workers for ART in sub-Saharan Africa: learning from experience -- capitalizing on new opportunities.Hum Resour Health. 2009; 7: 31Google Scholar, 39Ballard M Westgate C Alban R et al.Compensation models for community health workers: comparison of legal frameworks across five countries.J Glob Health. 2021; 1104010Google Scholar Section 5 includes a brief summary of the evidence on paying community health workers.
In many LMICS, the private sector is an important source of PHC provision.40Mackintosh M Channon A Karan A Selvaraj S Cavagnero E Zhao H What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries.Lancet. 2016; 388: 596-605Google Scholar, 41Basu S Andrews J Kishore S Panjabi R Stuckler D Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review.PLoS Med. 2012; 9e1001244Google Scholar Policy makers frequently express a desire to work with the private sector. However, the term private sector covers a heterogeneous set of providers, ranging from faith-based non-profit facilities that are well integrated into national health systems, to professionally trained clinicians operating private practices, to informally or untrained providers providing unregulated, low quality, even dangerous care. As noted, the Commission contends that universal PHC must rely predominantly on pooled public funds—but this does not preclude engaging with the private sector. Indeed, public financing mixed with private provision is widely adopted in OECD countries, where private providers are the main mode of provision of primary care in half of countries.42OECDHealth Systems Characteristics Survey.https: //www.oecd.org/els/health-systems/characteristics.htmDate: 2018Date accessed: June 30, 2021Google Scholar
Integrating the private sector into PHC platforms requires mechanisms to channel public funds to the private sector through purchasing arrangements. This pathway requires effective regulation, contracting capacity, and a broader set of purchasing institutions, including accreditation. In low-income countries, where informal private providers predominate and the public sector has insufficient resources for administering effective strategic purchasing and oversight, the best policy option is likely to be to start by providing good quality and affordable services in the public sector, while progressively strengthening regulation and professional bodies and collaborating with the private sector to develop referral pathways, training and qualification, and integration of clinical data.43McPake B Hanson K Managing the public–private mix to achieve universal health coverage.Lancet. 2016; 388: 62-130Google Scholar As both the public and private sectors develop greater capacities, the private sector can contribute to broader PHC functions, including public health surveillance and other essential public health functions, civil registration processes, the health management information system, and outbreak management.
This section sets the scene for the rest of the report by presenting data on several topics: how PHC is currently financed, how PHC providers are paid, and some of the features of how PHC is organised that are particularly relevant to financing arrangements. Key messages from this section are presented in panel 2.Panel 2Primary health care ( PHC) financing landscape–key messages•Despite the prominence of PHC in political commitments and policy statements, limited information is available on levels of, or trends in, financial resources for PHC. Different methods of calculating PHC spending are used, making it hard to compare expenditure data from different sources.•Annual government spending on PHC is $ 3 per capita in low-income countries and $ 16 per capita in lower-middle-income countries, which falls far short of any commonly used benchmark of the minimum amount needed to provide a basic package of health services.•Much of the variation across countries in estimated spending levels on PHC can be explained by national income level. However, there is also substantial variation in government spending on PHC among countries at similar income levels.•Higher levels of spending on PHC are generally associated with higher levels of service coverage. However, at any given spending level, there is substantial variation in performance, indicating that there is a need to spend better, as well as to spend more, on PHC.•Financing of, and spending on, PHC are fragmented. Governments typically invest in outpatient services, donor funding is used for prevention, and nearly half of private spending ( most of which is out of pocket) is on medicines. Although external funds are an important source, particularly in low-income settings, that augment government and out-of-pocket expenditures, they can also cause fragmentation.•Out-of-pocket spending on PHC remains unacceptably high, particularly in low-income countries, continuing to expose households to financial risk.•The most common method for paying public providers for PHC in low-income to middle-income countries is input-based budgets. Capitation-based payment systems for PHC are rare in low-income to middle-income countries.•Public providers have little autonomy over their spending, which limits their efficiency and responsiveness.
•Despite the prominence of PHC in political commitments and policy statements, limited information is available on levels of, or trends in, financial resources for PHC. Different methods of calculating PHC spending are used, making it hard to compare expenditure data from different sources.•Annual government spending on PHC is $ 3 per capita in low-income countries and $ 16 per capita in lower-middle-income countries, which falls far short of any commonly used benchmark of the minimum amount needed to provide a basic package of health services.•Much of the variation across countries in estimated spending levels on PHC can be explained by national income level. However, there is also substantial variation in government spending on PHC among countries at similar income levels.•Higher levels of spending on PHC are generally associated with higher levels of service coverage. However, at any given spending level, there is substantial variation in performance, indicating that there is a need to spend better, as well as to spend more, on PHC.•Financing of, and spending on, PHC are fragmented. Governments typically invest in outpatient services, donor funding is used for prevention, and nearly half of private spending ( most of which is out of pocket) is on medicines. Although external funds are an important source, particularly in low-income settings, that augment government and out-of-pocket expenditures, they can also cause fragmentation.•Out-of-pocket spending on PHC remains unacceptably high, particularly in low-income countries, continuing to expose households to financial risk.•The most common method for paying public providers for PHC in low-income to middle-income countries is input-based budgets. Capitation-based payment systems for PHC are rare in low-income to middle-income countries.•Public providers have little autonomy over their spending, which limits their efficiency and responsiveness.
To prioritise PHC expenditure, it is first necessary to measure what is currently spent. Empirical spending data allow policy makers to track existing expenditure, show how funds are currently being used, and make a case for increased commitments. Without data, it is hard to steer health systems toward stated goals, including equity, and even harder to track progress.
Analysing the financing arrangements for PHC requires clarity about what is ( and what is not) part of PHC. Measuring PHC spending is challenging for numerous reasons, beginning with the breadth of the definition of PHC. As noted in section 1, PHC can include functions outside the health sector. Yet for conceptual and practical reasons, the current standard framework for tracking all financial resources for health in a country restricts the boundaries of health spending to the health sector itself. This framework, the System of Health Accounts, does refer ( eg, through memorandum items for health promotion with a multisectoral approach) to expenditures by other sectors that clearly contribute to health, such as water and sanitation, but data on spending in these areas are not collected systematically.
Even within the health sector, there is no clear consensus on how to operationalise the definition of PHC in a robust expenditure monitoring exercise. The System of Health Accounts does not include a designated category for reporting spending on PHC.44WHOEstimation of PHC expenditure: technical note for discussion. WHO, Geneva2019Google Scholar Instead, it classifies health spending in various ways, including by type of provider and by type of health-care service. In practice, most countries ' definitions of PHC cut across these two classifications. Furthermore, the level of detail possible in System of Health Accounts reporting does not allow for accurate tracking of expenditure through to PHC services; instead System of Health Accounts measures rely on proxies derived from reported aggregates. For example, some countries do not distinguish expenditure on general outpatient services from that on specialised outpatient services, so their PHC expenditure estimates include both. The System of Health Accounts also does not distinguish among different levels of hospital care; however, in many countries district hospitals are part of PHC, while tertiary care is provided at centralised or regional hospitals. When used to estimate PHC expenditure, such approaches can give an impression of relatively high levels and shares of PHC spending. Panel 3 describes three countries ' different approaches to organising PHC, and how the differences are reflected in expenditure tracking.Panel 3Three countries ' approaches to defining primary health care ( PHC) Despite the existence of a global expenditure classification system, countries vary considerably in their models and conceptualisation of PHC, including how PHC spending is measured. Three examples, Thailand, South Africa, and the UK, are presented to show the breadth of this variety.Thailand * The Thailand case study was provided by S Viriyathorn, A Kulthanmanusorn, W Patcharanarumol, and V Tangcharoensathien, International Health Policy Programme, Ministry of Public Health, Thailand. * The Thailand case study was provided by S Viriyathorn, A Kulthanmanusorn, W Patcharanarumol, and V Tangcharoensathien, International Health Policy Programme, Ministry of Public Health, Thailand.In Thailand, PHC is defined differently in rural and urban areas. PHC in rural areas includes all services provided by the District Health Systems Network, which is comprised of public subdistrict health centres and district hospitals ( each of which serves a catchment of approximately 50 000 people). The District Health Systems Network is the first entry point to PHC for all people living in rural areas and provides a comprehensive range of services throughout the life course, including health promotion, disease prevention, and primary care services. It also provides public health functions, such as disease surveillance and response, and home visits, and supports multisectoral action to address social determinants of health and empower citizens and communities. In urban settings, meanwhile, PHC is less well-developed and most of the population uses hospital outpatient care directly, without any gatekeeping. In these settings, PHC is provided by the public and private hospital-based outpatient departments that provide a comprehensive range of primary care services similar to the District Health Systems Network.Based on these definitions, the Thailand National Health Account estimates PHC expenditure as the sum of general and dental outpatient curative and preventive care provided at subdistrict health centres, and at public and private hospitals.45National Health Accounts Working GroupThai national health accounts 2017–19. International Health Policy Program Foundation, Bangkok2021Google Scholar Between 2015 and 2019, total PHC spending was 38% to 40% of current health expenditure. About 60% of PHC spending was financed by three public-health insurance schemes. Household out-of-pocket payments represented between 4% and 7% of PHC spending, as the publicly-covered benefit package is comprehensive and medicines are fully subsidised. Per capita PHC spending increased from US $ 85·7 in 2015 to US $ 114·8 in 2019.South AfricaIn South Africa, a uniform budget structure for the country's health programming was designed to specifically designate subprogrammes for PHC. The classification system is standardised across provinces and districts. Overall, South Africa spent US $ 92·9 per capita on public sector PHC in 2019–20. The five main subprogrammes of PHC comprise 18·8% of provincial health expenditure. South Africa also has a large, separately designated, HIV and AIDS subprogramme that adds an additional 10·4%, bringing total PHC expenditure to 32·3% of public health expenditure, or 1·3% of gross domestic product. This budget subprogramme classification differs somewhat from the WHO and System of Health Accounts 2011 classification system: the 2016–17 National Health Accounts for South Africa showed PHC represented 28% of government health expenditure.UKThe National Health Service ( NHS) in the UK describes PHC as “ the first point of contact in the health care system, acting as the ‘ front door’ of the NHS ”. PHC is most closely linked to doctors in general practice, but also covers dentists, opticians, and pharmacists. Other professionals, such as nurses or physiotherapists, might also be part of a PHC team. Most primary care providers in the UK operate as independent contractors for the NHS. A range of services are contracted and financed through various models such as the General Medical Services or Personal Medical Services, Alternative Provider Medical Services, and Primary Care Trust Medical Services. According to the 2019–20 Annual Report and Accounts of the Department of Health and Social Care, primary care accounted for £12·6 billion ( 8·6%) of the total gross government expenditure on health of £145·27 billion. Prescribing costs, tracked separately, amounted to an additional £8·5 billion.
Despite the existence of a global expenditure classification system, countries vary considerably in their models and conceptualisation of PHC, including how PHC spending is measured. Three examples, Thailand, South Africa, and the UK, are presented to show the breadth of this variety.
Thailand * The Thailand case study was provided by S Viriyathorn, A Kulthanmanusorn, W Patcharanarumol, and V Tangcharoensathien, International Health Policy Programme, Ministry of Public Health, Thailand. * The Thailand case study was provided by S Viriyathorn, A Kulthanmanusorn, W Patcharanarumol, and V Tangcharoensathien, International Health Policy Programme, Ministry of Public Health, Thailand.
In Thailand, PHC is defined differently in rural and urban areas. PHC in rural areas includes all services provided by the District Health Systems Network, which is comprised of public subdistrict health centres and district hospitals ( each of which serves a catchment of approximately 50 000 people). The District Health Systems Network is the first entry point to PHC for all people living in rural areas and provides a comprehensive range of services throughout the life course, including health promotion, disease prevention, and primary care services. It also provides public health functions, such as disease surveillance and response, and home visits, and supports multisectoral action to address social determinants of health and empower citizens and communities. In urban settings, meanwhile, PHC is less well-developed and most of the population uses hospital outpatient care directly, without any gatekeeping. In these settings, PHC is provided by the public and private hospital-based outpatient departments that provide a comprehensive range of primary care services similar to the District Health Systems Network.
Based on these definitions, the Thailand National Health Account estimates PHC expenditure as the sum of general and dental outpatient curative and preventive care provided at subdistrict health centres, and at public and private hospitals.45National Health Accounts Working GroupThai national health accounts 2017–19. International Health Policy Program Foundation, Bangkok2021Google Scholar Between 2015 and 2019, total PHC spending was 38% to 40% of current health expenditure. About 60% of PHC spending was financed by three public-health insurance schemes. Household out-of-pocket payments represented between 4% and 7% of PHC spending, as the publicly-covered benefit package is comprehensive and medicines are fully subsidised. Per capita PHC spending increased from US $ 85·7 in 2015 to US $ 114·8 in 2019.
In South Africa, a uniform budget structure for the country's health programming was designed to specifically designate subprogrammes for PHC. The classification system is standardised across provinces and districts. Overall, South Africa spent US $ 92·9 per capita on public sector PHC in 2019–20. The five main subprogrammes of PHC comprise 18·8% of provincial health expenditure. South Africa also has a large, separately designated, HIV and AIDS subprogramme that adds an additional 10·4%, bringing total PHC expenditure to 32·3% of public health expenditure, or 1·3% of gross domestic product. This budget subprogramme classification differs somewhat from the WHO and System of Health Accounts 2011 classification system: the 2016–17 National Health Accounts for South Africa showed PHC represented 28% of government health expenditure.
The National Health Service ( NHS) in the UK describes PHC as “ the first point of contact in the health care system, acting as the ‘ front door’ of the NHS ”. PHC is most closely linked to doctors in general practice, but also covers dentists, opticians, and pharmacists. Other professionals, such as nurses or physiotherapists, might also be part of a PHC team. Most primary care providers in the UK operate as independent contractors for the NHS. A range of services are contracted and financed through various models such as the General Medical Services or Personal Medical Services, Alternative Provider Medical Services, and Primary Care Trust Medical Services. According to the 2019–20 Annual Report and Accounts of the Department of Health and Social Care, primary care accounted for £12·6 billion ( 8·6%) of the total gross government expenditure on health of £145·27 billion. Prescribing costs, tracked separately, amounted to an additional £8·5 billion.
Many countries ' expenditure reporting systems are inadequate for tracking expenditure on PHC. Although both OECD and WHO use the System of Health Accounts 2011 framework to track total health spending, only OECD collects disaggregated health spending ( based on both the health-care function and provider classifications) for its 34 high-income-country members. WHO began tracking health spending based on health-care functions in 2016, but does not report health spending classified by provider. In 2016, WHO reported PHC estimates for 93 countries, increasing to 98 countries in 2018 ( the most recent data available). Furthermore, breakdowns of public and private spending are only available in the WHO database for 57 countries in 2016, and 61 in 2018. Both the availability and the reliability of expenditure data on PHC in LMICs remain inadequate because of underinvestment in resource tracking systems, as well as the complexity of defining and tracking expenditure on PHC.6WHOUNICEFA vision for PHC in the 21st century: towards universal health coverage and the Sustainable Development Goals. WHO, Geneva2018Google Scholar
Finally, different international bodies and countries compile PHC expenditure using different definitions ( panel 4). Not only is there no agreed-on approach to estimate spending on PHC, but there is also no single database that provides globally comparable data for analysing PHC expenditure.Panel 4Working with Organisation for Economic Co-operation and Development ( OECD) and WHO definitions of primary health-care ( PHC) expenditure to construct an expenditure database on PHCTo prepare our landscape analysis of PHC expenditure across countries, the Commission needed to combine data from various sources, considering different definitions and assumptions. We focused on two key sources: OECD46Organisation for Economic Co-operation and DevelopmentOrganisation for Economic Co-operation and Development. Stat. Health expenditure and financing.https: //stats.oecd.org/index.aspx? DataSetCode=SHADate: 2021Date accessed: June 1, 2021Google Scholar and WHO.47WHOGlobal health expenditure database.https: //apps.who.int/nha/databaseDate: 2021Date accessed: August 3, 2021Google ScholarThe OECD definition of PHC begins with expenditure on basic health care services derived from the health care function ( HC) classification ( namely, the sum of spending on general outpatient curative care ( HC131), outpatient dental care ( HC132), home-based curative care ( HC14), and preventive care ( HC61-HC64).48Mueller M Morgan D Deriving preliminary estimates of primary care spending under the SHA system of health accounts 2011 framework. OECD Publishing, Paris2019Google Scholar An extended option also includes spending on pharmaceuticals. PHC expenditure is defined as expenditure on these services, limited to those delivered by ambulatory care providers derived from the health provider classification. WHO's definition of PHC uses only the HC classification. It starts with the same basic health care services in OECD's definition, and adds four additional components: •Curative outpatient care not elsewhere classified ( HC13).•Outpatient and home-based long-term health care ( HC33 and HC34).•80% of medical goods provided outside health care services ( HC5). Because HC5 also includes inpatient-related medicines purchased outside health care facilities, the 80% share is an assumption aimed to capture just the PHC element.44WHOEstimation of PHC expenditure: technical note for discussion. WHO, Geneva2019Google Scholar•80% of health system administration and governance expenditure ( HC7); this is included to represent the share of administrative expenditures related to policy and implementation costs for population-based public health interventions.Because the WHO definition includes spending on hospital-based general outpatient care, pharmaceuticals, and administrative costs, the OECD definition is a subset of the WHO definition. Therefore expenditure levels estimated using the OECD definition will always be lower.The Commission's definitionThe Commission used a definition of PHC expenditure based on the WHO definition to compile the data presented below. However, we excluded the administration and governance expenditures. This brings our definition closer to that used by the OECD and limits additional arbitrary assumptions. We are not suggesting that administration and governance are not important for PHC; rather, we believe that these inputs are better captured outside the direct measurement of PHC spending. The inclusion of administration costs disproportionately biases estimates of PHC in low-income countries upwards. Even with this restriction on the definition of PHC spending, our estimates have been calculated using a broad definition of PHC that does include some hospital care. Therefore, our estimates should be seen as an upper bound estimate.Details on how we combined data from the WHO and OECD databases to increase the number of countries we covered are presented in the appendix ( p 5).
To prepare our landscape analysis of PHC expenditure across countries, the Commission needed to combine data from various sources, considering different definitions and assumptions. We focused on two key sources: OECD46Organisation for Economic Co-operation and DevelopmentOrganisation for Economic Co-operation and Development. Stat. Health expenditure and financing.https: //stats.oecd.org/index.aspx? DataSetCode=SHADate: 2021Date accessed: June 1, 2021Google Scholar and WHO.47WHOGlobal health expenditure database.https: //apps.who.int/nha/databaseDate: 2021Date accessed: August 3, 2021Google Scholar
The OECD definition of PHC begins with expenditure on basic health care services derived from the health care function ( HC) classification ( namely, the sum of spending on general outpatient curative care ( HC131), outpatient dental care ( HC132), home-based curative care ( HC14), and preventive care ( HC61-HC64).48Mueller M Morgan D Deriving preliminary estimates of primary care spending under the SHA system of health accounts 2011 framework. OECD Publishing, Paris2019Google Scholar An extended option also includes spending on pharmaceuticals. PHC expenditure is defined as expenditure on these services, limited to those delivered by ambulatory care providers derived from the health provider classification. WHO's definition of PHC uses only the HC classification. It starts with the same basic health care services in OECD's definition, and adds four additional components: •Curative outpatient care not elsewhere classified ( HC13).•Outpatient and home-based long-term health care ( HC33 and HC34).•80% of medical goods provided outside health care services ( HC5). Because HC5 also includes inpatient-related medicines purchased outside health care facilities, the 80% share is an assumption aimed to capture just the PHC element.44WHOEstimation of PHC expenditure: technical note for discussion. WHO, Geneva2019Google Scholar•80% of health system administration and governance expenditure ( HC7); this is included to represent the share of administrative expenditures related to policy and implementation costs for population-based public health interventions.
Because the WHO definition includes spending on hospital-based general outpatient care, pharmaceuticals, and administrative costs, the OECD definition is a subset of the WHO definition. Therefore expenditure levels estimated using the OECD definition will always be lower.
The Commission used a definition of PHC expenditure based on the WHO definition to compile the data presented below. However, we excluded the administration and governance expenditures. This brings our definition closer to that used by the OECD and limits additional arbitrary assumptions. We are not suggesting that administration and governance are not important for PHC; rather, we believe that these inputs are better captured outside the direct measurement of PHC spending. The inclusion of administration costs disproportionately biases estimates of PHC in low-income countries upwards. Even with this restriction on the definition of PHC spending, our estimates have been calculated using a broad definition of PHC that does include some hospital care. Therefore, our estimates should be seen as an upper bound estimate.
Details on how we combined data from the WHO and OECD databases to increase the number of countries we covered are presented in the appendix ( p 5).
Definitions matter. They signal what is prioritised and valued, and they shape norms regarding how services should be organised. They also influence how data are collected and presented. There is a trade-off between using a simple global definition and accounting for country-specific definitions to permit more accurate reporting. In these early days of PHC expenditure reporting, what is most crucial is for each country to choose a way of operationalising PHC expenditure estimates so it can track its progress. Eventually, however, a consistent definition across countries will be needed to allow for cross-country comparisons and global monitoring of expenditure on PHC.
In generating our estimates of current levels of PHC expenditure, this Commission was constrained by both the levels of current reporting and the definitions used by the organisations that compile data.
The Commission's approach to measuring expenditure on PHC is presented in panel 4, along with the thinking behind it. For the purposes of tracking expenditures on PHC in the future, this Commission favours using an operational definition based on service delivery platforms for PHC: population-based public health services, community health services, health centres, and first-level hospitals. This is because financing arrangements typically channel resources to providers and platforms, rather than to interventions or services. We also take the normative position that PHC should not be delivered through higher-level hospitals, because improving financing arrangements should focus on driving resources to and supporting use at the appropriate level of care, which brings services as close as possible to people and delivers them at the lowest cost. To estimate PHC expenditure using a platform-based approach requires data that cross-classify between health care function and provider category. However, because currently available data from WHO are only reported by health-care function, we are limited to estimating PHC expenditure using a service-based ( rather than a platform-based) approach. We also made some modifications to the PHC expenditure reported by the WHO for the purposes of our analysis ( panel 4).
WHO reported data on total PHC spending on 98 countries for 2018 and government spending on PHC on 61 of these. We observed that the WHO database did not provide data on government spending on PHC for all OECD countries. In order to compare spending levels in high income countries with those in LMICs, we constructed PHC expenditure for OECD countries from data on expenditure by financing scheme, using expenditure by government and compulsory schemes to proxy for government spending on PHC. We used exchange rate data from the Global Health Expenditure Database to convert the raw data from local currency. With the addition of reconstructed government spending on PHC per capita from the OECD database following the WHO definition, the total number of countries providing data on government spending on PHC increased to 90 countries.
Despite data limitations, our analyses have identified some notable patterns in the levels and sources of PHC spending across countries. Table 1 presents overall health expenditure data by country income group for 2018. The table shows that total expenditure on PHC in low-income countries is $ 24 per capita and in lower-middle-income countries it is $ 52 per capita. Government spending on PHC is even more meagre, at $ 3 in low-income countries and $ 16 in lower-middle-income countries, which falls short of the WHO estimate of the per capita recurrent cost for PHC of $ 65 in low income countries and $ 59 in lower-middle income countries10Stenberg K Hanssen O Bertram M et al.Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study.Lancet Glob Health. 2019; 7: e1500-e1510Google Scholar ( section 3). Although the share of government health spending allocated to PHC is similar in LMICs and high-income countries, government spending on PHC as a share of total PHC spending is lower in low-income countries than in high-income countries and the same is true of the share of government PHC spending in relation to GDP.Table 1Summary of health expenditure in 201840Mackintosh M Channon A Karan A Selvaraj S Cavagnero E Zhao H What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries.Lancet. 2016; 388: 596-605Google Scholar, 41Basu S Andrews J Kishore S Panjabi R Stuckler D Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review.PLoS Med. 2012; 9e1001244Google ScholarLevel of spending per capita ( US $) Share of spending (%) ( Total) Current health spendingDomestic general government expenditure on healthTotal PHC spendingDomestic general government spending on PHCOut-of-pocket spending on PHCExternal spending on PHCPHC spending as a share of current health spendingDomestic general government spending on PHC as a share of total PHC spendingDomestic general government spending on PHC as a share of GDPDomestic general government spending on PHC as a share of domestic general government expenditure on healthOut-of-pocket spending on PHC as a share of total PHC spendingExternal spending on PHC as a share of total PHC spendingLow-income group40 ( n=16) 8 ( n=16) 24 ( n=16) 3 ( n=14) 12 ( n=14) 8 ( n=14) 59% ( n=16) 13% ( n=14) < 1% ( n=14) 33% ( n=14) 44% ( n=14) 35% ( n=14) Lower-middle-income group104 ( n=25) 44 ( n=25) 52 ( n=25) 16 ( n=24) 23 ( n=24) 8 ( n=24) 52% ( n=25) 29% ( n=24) < 1% ( n=24) 36% ( n=24) 49% ( n=24) 14% ( n=24) Upper-middle-income group416 ( n=20) 242 ( n=20) 169 ( n=20) 73 ( n=19) 65 ( n=19) 6 ( n=19) 42% ( n=20) 45% ( n=19) 1% ( n=19) 34% ( n=19) 39% ( n=19) 5% ( n=19) High-income group3310 ( n=34) 2355 ( n=34) 1312 ( n=34) 840 ( n=33) 318 ( n=33) 0 ( n=33) 42% ( n=34) 59% ( n=33) 2% ( n=33) 36% ( n=33) 28% ( n=33) < 1% ( n=33) Total1306 ( n=95) 907 ( n=95) 523 ( n=95) 328 ( n=90) 139 ( n=90) 5 ( n=90) 48% ( n=95) 41% ( n=90) 1% ( n=90) 35% ( n=90) 39% ( n=90) 10% ( n=90) GDP=gross domestic product. PHC=primary health care. OECD=Organisation for Economic Co-operation and Development. For total PHC spending, WHO provides data for 98 countries and OECD provides data on high income countries that overlap with WHO data but with an additional five countries which brings a total of combined data for 103 countries.. However, we excluded eight countries due to the inconsistency in how they reported health spending by functions ( France, Greece, Ireland, Italy, Mexico, Portugal, UK, and USA). The total number of countries for which we present data is therefore 95 countries. For government spending on PHC, WHO provides data for 61 countries and OECD provides data for an additional 36 high income countries that brings a total of combined data for 97 countries. However, we excluded seven countries due to the inconsistency in how they reported health spending by functions ( France, Greece, Ireland, Italy, Portugal, UK, and USA). This gives a total number of 90 countries for this indicator. For five countries, the Global Health Expenditure Database reports total PHC spending data but no disaggregation by financial source ( ie government, external, and private [ Bosnia and Herzegovina, Democratic Republic of Congo, Ethiopia, Ghana, and Uruguay ]). Only five high-income countries report external funding for PHC ( Barbados, Mauritius, Seychelles, St Kitts and Nevis, and Trinidad and Tobago). For other high-income countries external spending is negligible or zero. Averages are unweighted means across countries. To calculate the average of ratios, we calculated the ratio for each country and took the average for each income group. The sum of government, external, and out-of-pocket spending will not be equal to the total spending due to the omission of other types of private spending, such as voluntary private insurance. The gap is bigger in high-income countries because private insurance is more common in high-income countries. Although out-of-pocket spending on PHC is available in the OECD database, WHO only reports domestic private spending on PHC. To estimate the out-of-pocket spending for PHC in low-income to middle-income countries, we took the ratio of total out-of-pocket spending on health to total domestic private spending on health and multiplied it by private spending for PHC for each country. Open table in a new tab
GDP=gross domestic product. PHC=primary health care. OECD=Organisation for Economic Co-operation and Development. For total PHC spending, WHO provides data for 98 countries and OECD provides data on high income countries that overlap with WHO data but with an additional five countries which brings a total of combined data for 103 countries.. However, we excluded eight countries due to the inconsistency in how they reported health spending by functions ( France, Greece, Ireland, Italy, Mexico, Portugal, UK, and USA). The total number of countries for which we present data is therefore 95 countries. For government spending on PHC, WHO provides data for 61 countries and OECD provides data for an additional 36 high income countries that brings a total of combined data for 97 countries. However, we excluded seven countries due to the inconsistency in how they reported health spending by functions ( France, Greece, Ireland, Italy, Portugal, UK, and USA). This gives a total number of 90 countries for this indicator. For five countries, the Global Health Expenditure Database reports total PHC spending data but no disaggregation by financial source ( ie government, external, and private [ Bosnia and Herzegovina, Democratic Republic of Congo, Ethiopia, Ghana, and Uruguay ]). Only five high-income countries report external funding for PHC ( Barbados, Mauritius, Seychelles, St Kitts and Nevis, and Trinidad and Tobago). For other high-income countries external spending is negligible or zero. Averages are unweighted means across countries. To calculate the average of ratios, we calculated the ratio for each country and took the average for each income group. The sum of government, external, and out-of-pocket spending will not be equal to the total spending due to the omission of other types of private spending, such as voluntary private insurance. The gap is bigger in high-income countries because private insurance is more common in high-income countries. Although out-of-pocket spending on PHC is available in the OECD database, WHO only reports domestic private spending on PHC. To estimate the out-of-pocket spending for PHC in low-income to middle-income countries, we took the ratio of total out-of-pocket spending on health to total domestic private spending on health and multiplied it by private spending for PHC for each country.
A descriptive analysis of PHC expenditure patterns is presented in the appendix ( p 9). There is a strong correlation between income level and health expenditure on PHC, yet there is also substantial variation within any given economic level in how much governments spend on PHC. For example, spending in low income countries ranged from $ 8 to $ 46 and in lower middle-income countries, spending ranged from $ 11 to $ 120 per capita ( appendix p 9). The share of PHC in current health expenditure ( which includes expenditure from public, private, and external sources) decreases as countries ' income levels increase—again, substantial variation exists at every income level. For example, the share in low income countries ranged from 29% to 86% ( appendix p 10). Priority given to PHC within government health spending is similar on average across income groups, although there are variations in commitment at any given income level and this is more pronounced in low-income and lower-middle-income countries. However, the government share of total PHC spending was lowest in low-income countries, where both external sources and private spending ( in LMICs, predominantly out-of-pocket spending) has a substantial role in financing PHC. Indeed only 13% of PHC financing in low-income countries is public.
Financing for PHC in low-income and lower-middle-income countries is dominated by relatively unregulated private expenditure, most of which is out of pocket ( figure 1). Only in high-income countries does the average share of out-of-pocket spending on PHC fall below 30% ( although even in this group of countries, there is a long tail of countries with substantial out-of-pocket spending for PHC, suggesting that the issue is one of policy, not availability of resources). Figure 1 also compares the out-of-pocket share of PHC spending with the out-of-pocket share of non-PHC spending. At all country income levels, households are more exposed to out-of-pocket spending for PHC than for other health spending. This finding suggests that pooling arrangements provide less coverage for PHC and that households are more likely to be exposed to catastrophic financial consequences of paying for PHC—this underlines the importance of including PHC in benefit packages. The high level of out-of-pocket spending for PHC is particularly worrisome in LMICs, where the majority of people die from preventable causes that could be managed at the PHC level, and where poor people might be more likely to forego PHC than advanced specialist care. We contend that the lack of pooling for PHC runs counter to a progressive universalism approach to PHC, and exacerbates inequities. Finally, it is important to note that these figures do not account for people who are not able to access PHC at all; this is a general limitation of any equity analysis based on incurred expenditure.Figure 1Out-of-pocket household spending as a share of total spending for PHC and non-PHC in 2018, by country incomeShow full captionOut-of-pocket share of PHC is calculated as out-of-pocket spending on PHC as a share of total PHC spending. Out of pocket share of non-PHC is calculated as out-of-pocket spending on non-PHC as a share of total non-PHC spending. The box represents IQR; the ends of the whiskers represent the minimum and maximum value; the bold horizontal line represents the median. PHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
Out-of-pocket share of PHC is calculated as out-of-pocket spending on PHC as a share of total PHC spending. Out of pocket share of non-PHC is calculated as out-of-pocket spending on non-PHC as a share of total non-PHC spending. The box represents IQR; the ends of the whiskers represent the minimum and maximum value; the bold horizontal line represents the median. PHC=primary health care.
It is also notable that about half of private spending on PHC ( most of which is out of pocket in LMICs) is for medical goods purchased outside health services ( figure 2). Much of this is likely to be for medicines; for example, The Lancet Commission on Essential Medicines for Universal Health Coverage49Wirtz VJ Hogerzeil HV Gray AL et al.Essential medicines for universal health coverage.Lancet. 2017; 389: 403-476Google Scholar reported that more than 62% of pharmaceutical expenditure in LMICs was from private sources, which is likely to be mostly out-of-pocket spending considering the low levels of prepaid and pooled resources.Figure 2Components of PHC spending by financial source in low-income to high-income countries in 2018Show full captionFigures exclude dental care and home care. Medical goods only include medicines and other medical goods purchased outside of outpatient facilities. Private spending includes individuals paying out of pocket and other domestic private sources, such as private insurance ( voluntary and compulsory). External spending includes the use of grants, concessional loans, and aid in kind from outside the country. PHC=primary health careView Large Image Figure ViewerDownload Hi-res image Download ( PPT)
Figures exclude dental care and home care. Medical goods only include medicines and other medical goods purchased outside of outpatient facilities. Private spending includes individuals paying out of pocket and other domestic private sources, such as private insurance ( voluntary and compulsory). External spending includes the use of grants, concessional loans, and aid in kind from outside the country. PHC=primary health care
In LMICs, the largest share of government expenditure is for outpatient care. Within this spending category, government health spending is highly skewed towards health-worker salaries. WHO's analysis of the Global Health Expenditure Database indicates that for 136 countries, 57% of public spending on health is allocated to wages.50Lauer JA Soucat A Araujo E et al.Paying for needed health workers for the SDGs: an analysis of fiscal and financial space.in: Buchan J Dhillon IS Campbell J Health employment and economic growth: an evidence base. World Health Organization, Geneva2017Google Scholar For PHC, in which few other inputs are used, salaries are likely to be an even higher share. This balance of spending likely represents a source of inefficiency if, after paying the wage bill, insufficient funds are left to purchase other inputs required for health workers to work effectively.
In low-income and lower-middle income countries, where external funds are a significant contributor to PHC expenditure, donor funds are predominantly spent on prevention. Figure 2 suggests significant fragmentation of PHC expenditure across financing sources.
Does the level of spending matter? This Commission examined whether there is a relationship between overall government spending on PHC and coverage of key services ( figure 3). We used the universal health coverage ( UHC) service coverage index51WHOPrimary health care on the road to universal health coverage: 2019 global monitoring report. WHO, Geneva2019Google Scholar as a proxy for PHC service coverage—of the 14 variables indexed, 11 relate to core PHC services ( in addition, the index includes hospital bed density, health-worker density, and capacity to implement the International Health Regulations). Two key findings emerge from the analysis. First, higher government spending on PHC is strongly associated with better service coverage. This relationship remains strong after adjustment for GDP per capita ( result not shown), which figure 3 suggests could be a potential confounder. Second, for any given level of government spending, particularly below $ 50 per capita, there is substantial variation in performance on the service coverage index. For example, countries that spent between $ 50 and $ 55 have a range of UHC index from 42 to 68. Whether there is a causal relationship underlying the association between government spending on PHC and service coverage is hard to show. However, the data are consistent with the notion that countries should not only spend more but also spend better to achieve improved coverage of core PHC services.Figure 3Government spending on PHC versus UHC index, 2018Show full captionPHC=primary health care. UHC=universal health coverage.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
PHC=primary health care. UHC=universal health coverage.
Low-income countries depend substantially on external sources to pay for PHC ( appendix p 11). External funding typically focuses on prevention and treatment of single diseases, which can contribute to fragmentation in financing arrangements and PHC delivery—this is especially evident when externally funded programmes are not part of government planning and budgeting processes. Community health worker programmes, which often form the backbone of PHC delivery, are also highly dependent on donor funding: an estimated 60% of funding for community health worker programmes in sub-Saharan Africa comes from external sources, much of which is funding for vertical, disease-specific programmes.52Gichaga A Masis L Chandra A Palazuelos D Wakaba N Mind the global community health funding gap.Glob Health Sci Pract. 2021; 9: S9-17Google Scholar The fragmentation of PHC financing related to reliance on donor funding is due to requirements for tracking and reporting separately on donor funded activities. It might also be a source of inefficiency due to the so-called start-stop nature of donor funding ( as compared with government budgeting).53Barr A Garrett L Marten R Kadandale S Health sector fragmentation: three examples from Sierra Leone.Global Health. 2019; 15: 8Google Scholar
There are limitations to these analyses. First, use of the WHO's broad PHC expenditure definition has the effect of biasing the estimates of PHC spending upwards ( because of the inclusion of outpatient services provided in hospitals). Any definition that uses a narrower scope would produce lower estimates of PHC expenditure. For example, in 2019, the OECD reported that spending on primary care within ambulatory settings represented just 12% of health expenditure; this increases to 17% when PHC services delivered in hospital settings are included, and to 34% by including retail pharmaceuticals.48Mueller M Morgan D Deriving preliminary estimates of primary care spending under the SHA system of health accounts 2011 framework. OECD Publishing, Paris2019Google Scholar
Second, data are only available for 95 out of 192 countries and for a single point in time. The spending estimates for some income groups are affected by the small number of countries in each group. Most importantly for our purposes, the absence of consistent and comparable data over time means that it is not possible to easily identify which countries are increasing or sustaining their commitments to PHC. Therefore, although these results are informative, throughout the report we also include more qualitative assessments of countries ' progression towards adequate financing for PHC.
Even with our limited dataset, we argue that LMICs need to spend more on PHC to provide equitable and universal access PHC that is people centred. Further, the Commission contends that adopting a definition of PHC that is consistent with the vision of providing health care at the lowest possible level, and then supporting countries to collect and report data disaggregated in this way, are essential steps toward improving the quality of national data on PHC expenditure. Data, after all, are an essential part of the strategy for monitoring and actively protecting resources for PHC going forward, and for enabling countries to show their progress in increasing their commitment to PHC.52Gichaga A Masis L Chandra A Palazuelos D Wakaba N Mind the global community health funding gap.Glob Health Sci Pract. 2021; 9: S9-17Google Scholar
Countries differ widely in terms of how PHC is structured and organised, including whether PHC includes community health workers and how they link to health facilities. Yet, although the availability of data on PHC expenditure in LMICs is improving, there is still little systematically collected cross-country data on the financial arrangements of LMIC health systems and provider payment structures. This contrasts with the data collected from OECD countries, for which the Health System Characteristics Survey provides comparable data on how countries finance, deliver, allocate resources to, and govern their health systems.42OECDHealth Systems Characteristics Survey.https: //www.oecd.org/els/health-systems/characteristics.htmDate: 2018Date accessed: June 30, 2021Google Scholar To address this important data gap, in this Commission, we did our own cross-sectional survey in LMICs with the aim of collecting data on the key financing-related features of how PHC is organised, and on how PHC providers are paid. The questionnaire was sent in a personal email to health financing experts identified through the networks of the London School of Hygiene & Tropical Medicine, the World Bank, Results for Development, and WHO. The survey could be completed in two ways: either through self-completion or through a videoconference interview ( for methods see appendix p 13). The survey was sent to 107 LMICs ( one expert from each country), of which there were 75 responses: 22 from low-income countries, 22 from lower middle-income countries, and 31 from upper middle-income countries. Figure 4, Figure 5, Figure 6, Figure 7, Figure 8 present key findings from this survey.Figure 4Organisation and governance of public PHC providersShow full captionData indicate the proportion of countries with each organisational and governance arrangement in place. Data are disaggregated by country income group. PHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT) Figure 5Degree of autonomy for public PHC providersShow full captionData indicate the proportion of countries in which public PHC providers have autonomy in how they function. Data are disaggregated by country income group. PHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT) Figure 6Formal and informal user fees at public PHC providersShow full captionData indicate the user fee policy in place in public PHC providers across surveyed countries ( categories are mutually exclusive). Data are disaggregated by country income group. PHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT) Figure 7Provider payment mechanisms for public PHC providersShow full captionData indicate the type of payment system used in public PHC providers across surveyed countries ( categories are mutually exclusive). Data are disaggregated by country income group. Population payment refers to capitation. Input-based payment refers to global budget, line item budget, and direct payment of salaries by government. Service-based payment refers to fee-for-service, case-based payment and pay-for-performance. PHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT) Figure 8Paying community health workersShow full captionData indicate how community health workers delivering services on behalf of the government are remunerated in surveyed countries ( categories are mutually exclusive). Data are disaggregated by country income group.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
Data indicate the proportion of countries with each organisational and governance arrangement in place. Data are disaggregated by country income group. PHC=primary health care.
Data indicate the proportion of countries in which public PHC providers have autonomy in how they function. Data are disaggregated by country income group. PHC=primary health care.
Data indicate the user fee policy in place in public PHC providers across surveyed countries ( categories are mutually exclusive). Data are disaggregated by country income group. PHC=primary health care.
Data indicate the type of payment system used in public PHC providers across surveyed countries ( categories are mutually exclusive). Data are disaggregated by country income group. Population payment refers to capitation. Input-based payment refers to global budget, line item budget, and direct payment of salaries by government. Service-based payment refers to fee-for-service, case-based payment and pay-for-performance. PHC=primary health care.
Data indicate how community health workers delivering services on behalf of the government are remunerated in surveyed countries ( categories are mutually exclusive). Data are disaggregated by country income group.
Figure 4 presents results on indicators of how PHC services are organised that have implications for provider payment. The requirement for people to register with a public PHC provider, necessary for population-based forms of provider payment such as capitation, is uncommon in low-income and lower-middle-income countries, but more common in upper-middle-income countries. People are not restricted in their choice of public PHC providers in two-thirds of low-income and lower-middle-income countries. More restrictions on choice of provider ( often in relation to the requirement to register with a provider) in upper-middle-income countries suggest that these countries seek to encourage greater consistency in use of PHC providers. Gatekeeping ( in which individuals are required, or have strong financial incentives, to be referred by primary care providers to access higher-level services) is used in less than half of low-income countries. It is present in nearly three-quarters of upper-middle-income countries, although in practice these systems might frequently be circumvented. Dual practice ( when a doctor works in both public and private sector practices) is common in all LMIC settings.
The extent of provider autonomy links closely with provider payment arrangements, because changing providers ' incentives without enabling them to make decisions about how to use their resources constrains the potential for improvements in responsiveness and efficiency. Figure 5 shows that public sector PHC providers generally lack autonomy, with fewer than half of the countries included in the survey granting providers autonomy in any domain. More specifically, public PHC providers in fewer than 40% of LMICs have autonomy to manage and retain income, nor do they typically have the autonomy to top-up the salaries of their staff to reward performance. Provider autonomy to hire and fire staff, for example, tends to increase as country income level increases, with PHC providers in more than 40% of upper-middle-income countries able to make such decisions. There is a similar pattern across country income groups when it comes to autonomy to choose the mix of services to provide. Regarding procurement of medicines, however, autonomy is greatest in lower-middle-income countries—this might reflect chronic shortages of inputs.
This Commission's survey confirms that user fees ( whether formal or informal) are a common source of payment for PHC in low-income and lower-middle-income countries, although many countries have exemptions in place for specific population groups or types of services. Figure 6 shows that the prevalence of user fees as a funding source in the public sector decreases as countries get richer: about 95% of low-income countries report that there is some form of user fee, whereas fewer than 60% of upper-middle-income countries have them. Informal user fees remain a problem in both low-income and lower-middle-income countries; upper-middle-income countries do considerably better in this regard.
The survey also provided insights into how PHC providers are paid from pooled funds ( most commonly government and social health insurance payers). Figure 7 shows that these two types of payer rely fully on input-based budgets in more than 60% of low-income countries, and on input-based budgets in combination with fee-for-service in a further 30% of low-income countries; the relevance of the type of budgeting used for PHC is discussed in detail in section 4. Service-based payment, which includes fee-for-service, case-based payment or pay-for-performance, are also commonly used by government and social health insurance payers, most notably in lower-middle-income countries where it is present in almost 60% of PHC systems. Population-based, or capitation, payment systems are rarely used in low-income countries. At higher income levels, there is wider use of blended payment methods that combine different payment mechanisms and thus open up the possibility of a greater role for capitation. Capitation payment, alone or in combination with other payment methods, is used in almost 40% of middle-income countries. Our survey also found that in countries where capitation is used, around two-thirds of PHC systems adjust the payment amounts to reflect variations in health needs ( data not shown).
These findings from this Commission's survey support other evidence about the role of user payments in low- and lower-middle-income countries, and show that countries at higher levels of income are making greater use of capitation or blended payment as part of the move towards paying for people-centred PHC. These new data also provide a baseline for future efforts to track developments in PHC financing in LMICs.
The Commission's provider payment survey also collected data on how community health workers are paid. Figure 8 shows that more than 80% of lower-middle-income countries and more than 90% of low-income countries reported having some form of community health workers, compared with just over half of upper-middle-income countries. The most common form of payment for community health workers was by salary, although payment per day or per activity was also common in low-income and lower-middle-income countries. A small minority of countries have their community health workers paid in kind only, such as gifts or training; no payment for community health workers was reported only in a small minority ( less than 5%) of low-income countries. Evidence on different ways of paying community health workers is presented in section 5.
PHC needs to constantly respond and adapt to new challenges created by changes in the environment, population health needs, and our expanding understanding of the importance of pursuing equity. Improving financing arrangements is one key way to influence adaptations of PHC. The growing burden of non-communicable diseases, the inevitable emergence of new pandemics, rapidly changing digital technologies for delivery and administration, and the growth of the private sector will all force the delivery of PHC—and its financing arrangements—to change as well. Responding to changing conditions also generates many opportunities for policy makers to influence PHC and improve its capacity to provide people-centred care that better supports social goals, such as UHC and equity, on the national and global scales. Financing should, at a minimum, not impede needed changes in service delivery; at best, financing arrangements can serve as a transformational force. This section describes several challenges for delivering PHC and the promising approaches to organising PHC financing that are elaborated further throughout the rest of the report.
Coordination and integration of services is at the heart of people-centred care. PHC has been described as the coordination mechanism that links primary care, community care, specialised care, wider public health interventions, and long-term care services.16WHOThe World Health Report 2008: primary health care now more than ever. World Health Organization, Geneva2008Google Scholar However, efforts to improve coordination and integration often face challenges at the interfaces of services and specialities; as noted, in LMICs, many challenges have arisen from the absence of integration between PHC and donor-financed vertical programmes, such as those focused on maternal health or HIV and AIDS. Improving coordination among different PHC services is as important as coordinating PHC with higher levels of the health system.
Problematic financing arrangements are frequently at the core of these challenges. Different financing mechanisms for different sources of funds, the means of allocation and management of flows of funding, and complicated payment mechanisms all act as major barriers to the implementation of more integrated approaches to service delivery.54Nolte E Woldmann L Financing and reimbursement.in: Amelung V Stein V Goodwin N Balicer R Nolte E Suter E Handbook integrated care. Springer International Publishing, Switzerland2021: 341-364Google Scholar As noted in the Commission's case study on Chile, for example, the absence of strategic coordination between the capitation payment for PHC and the application of diagnosis-related groups for hospital care made clinical coordination and integration of care difficult.55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar Where PHC is provided by an unorganised private sector and paid for by out-of-pocket payments, care can be fragmented and create excessive financial burdens. In this situation, for example, every provider might require the same diagnostic tests to be repeated and there can be excess prescription of branded medicines.41Basu S Andrews J Kishore S Panjabi R Stuckler D Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review.PLoS Med. 2012; 9e1001244Google Scholar, 56Garg S Tripathi N Ranjan A Bebarta KK Comparing the average cost of outpatient care of public and for-profit private providers in India.BMC Health Serv Res. 2021; 21: 838Google Scholar Donor funding can be a further impediment to integration. How health financing arrangements can support integration is explored in section 5.
One major development in PHC, as indeed in all sectors, has been the rapid development of new digital technologies. In this Commission, we reviewed the published and grey literature regarding two questions: where have digital technologies facilitated financing of health and PHC? And how have financing arrangements been adapted to facilitate the digital delivery of PHC ( appendix p 17)? After the literature review, a roundtable discussion took place among 13 digital and health financing experts ( academics, practitioners, and donors) and the Commissioners captured recent and unpublished experiences and insights ( for methods see appendix p 35). Four main messages emerged from this process. First, very little robust evidence exists on the impact of digital technologies on health financing objectives, including financing for PHC. Rigorous research in this area is urgently needed. Second, digital technologies offer great promise to improve the efficiency of resource mobilisation and purchasing arrangements; however, caution is warranted. There are risks, such as fragmentation if it leads to multiple small funding pools or parallel electronic patient information systems. Another risk is misalignment with UHC equity principles; for example, for the moment, digital access is much higher in cities, although this is changing rapidly. Third, to date, digital technologies related to financing have mostly been applied to health-care purchasing. For example, in the Philippines, digitised claims analysis using artificial intelligence is being used to detect fraud; 57Pague B Alcantara AC Claims management using artificial intelligence: experiences from PhilHealth in the Philippines. iHEA 2021 congress: health economics in a time of global change; 2021; Virtual congress: iHEA.https: //cdn.ymaws.com/www.healtheconomics.org/resource/resmgr/2021 virtual conference/program pdf s/ihea 2021 - full program boo.pdfDate: 2021Date accessed: December 15, 2021Google Scholar in India, provider payment has been facilitated through an online system for data reporting and online pay-for-performance of Accredited Social Health Activists.58Rose AF Kumar A Perception and performance: impact of ASHA-soft on ASHA workers in rural field practice area of a medical college in central Karnataka.Ann Comm Health. 2020; 8: 14184-14188Google Scholar Some applications to revenue mobilisation and pooling have also been documented: in Ghana, mobile phone apps have simplified payment of health insurance contributions and enrolment reminders.59Boaheng JM Amporfu E Ansong D Osei-Fosu AK Determinants of paying national health insurance premium with mobile phone in Ghana: a cross-sectional prospective study.Int J Equity Health. 2019; 18: 50Google Scholar Fourth, little has been documented about any actual adjustments to financing arrangements to facilitate online and digital delivery of PHC, beyond measures to include remote consultations in insurance benefit packages. However, this area is developing rapidly ( for example, the introduction of Babyl, an artificial intelligence-supported digital health service provider, in Rwanda) 60Burki T GP at hand: a digital revolution for health care provision?.Lancet. 2019; 394: 457-460Google Scholar and often without formal assessment or evaluation. Financing arrangements must be adapted if digital solutions are to be included in pooled funding arrangements, and provider payment levels need to be adjusted to cover additional activities required to integrate new technology enabled activities.
Most recently, the public health and social measures put in place to address the COVID-19 pandemic, such as lockdowns and quarantines, accelerated the development and use of various forms of digital health-care delivery, including remote consultations and home-based monitoring. Financing arrangements were quickly adapted to enable these changes, such as extending benefit packages to include remote consultation. PHC needs to continue to embrace new technologies that support coordination, interoperability, and regulation; and financing arrangements should continue to adapt to accommodate these. It is also important to avoid a situation where multiple solutions act independently and foment fragmentation. The key will be to allow flexible financing approaches to support these developments, while ensuring that they are thoughtfully integrated into the wider health system to induce efficiency gains without sacrificing equity. This is discussed throughout the Commission.
The data presented above show the importance of expenditure on medicines—which is sometimes as high as 40–50% of all expenditure and is often paid for out-of-pocket through private pharmacies—in PHC spending in many LMICs ( figure 2). However, medicines are often out of stock in public health facilities or not included in provider payments. Patients then pay out of pocket for medicines purchased in private pharmacies, representing a substantial barrier to the use of medically appropriate and high quality medicines. This is particularly apparent for non-communicable diseases.61Beran D Pedersen HB Robertson J Noncommunicable diseases, access to essential medicines and universal health coverage.Glob Health Action. 2019; 121670014Google Scholar Such out-of-pocket expenditure leads to inefficient use of medicines and financial burdens for patients.
Effective financing arrangements for medicines for PHC should have two key outcomes: to provide financial protection against the costs of medicines, and to encourage efficient use of resources. Financing arrangements for paying for medicines should focus on four goals. ( 1) Including essential medicines in the PHC package that is covered by pooling arrangements, including those needed for management of chronic conditions. ( 2) Ensuring that sufficient funds are mobilised to supply these medicines and deploying all available policy tools to procure medicines efficiently ( including essential medicines lists, bulk procurement, and market shaping to secure favourable prices). ( 3) Encouraging efficient use of medicines through appropriate incentives to providers, dispensers, and patients. ( 4) Enabling new ways for people to access medicines that allow them greater control and easier access, for example, through self-service vending machines,62McVeigh T South Africa's latest weapon against HIV: street dispensers for antiretrovirals.The Guardian. July 17, 2016; https: //www.theguardian.com/world/2016/jul/17/atms-dispense-antiretrovirals-south-africa-hivDate accessed: December 3, 2021Google Scholar e-prescription and e-pharmacy.
In section 2, we provided an overview of how PHC is financed and how PHC providers are paid. Although the findings are instructive, it is clear that much of the global expenditure data on PHC are problematic. A consensus on a consistent operational definition of PHC would enable better expenditure analyses—it would also help to prioritise PHC, promoting the normative message that PHC should not be provided at higher level hospitals, and enable countries to better track their progress. Generating agreement on a definition requires taking a position on the trade-offs between, on the one hand, allowing flexible definitions that fully capture local particulars, and, on the other hand, having a consistent definition that enables global monitoring and comparisons.
Even if the data presented in this Commission significantly overestimate PHC spending, they still show that the levels of government spending on PHC in low-income and lower-middle-income countries are far from sufficient, and that a considerable share of current financing comes from out-of-pocket, not pooled, resources. Furthermore, the relationship between PHC spending and service coverage, as measured using the UHC service coverage index, shows that existing money could be spent more effectively. These findings underpin the Commission's overarching message: that countries need to spend more and spend better on PHC. Better spending would mean replacing out-of-pocket spending on PHC with pooled public sources ( see sections 3 and 4); ensuring that the resources intended for PHC reach the frontline providers; reducing fragmentation of funding; and expanding provider autonomy by improving how providers are paid to better incentivise people-centred PHC ( see section 5).
This section addresses how to take a people-centred approach to raising more prepaid and pooled funding for PHC by mobilising more funding for health overall. The issue of how resources are allocated to PHC from the overall health budget is addressed in the next section, although these are closely intertwined in practice. This section includes: an overview of the challenges faced in mobilising and pooling financing for health, a vision for increasing resources for health, and some possible strategies to pursue this vision. It is important to note throughout that stakeholders beyond the health sector have the greatest responsibility for raising additional resources for health. The ministry of finance is key because it both has responsibility for raising government revenue and wields significant power in budget-setting negotiations with spending ministries, such as the ministry of health. Key messages from this section are presented in panel 5.Panel 5Mobilising and pooling resources for primary health care ( PHC) –key messages•Government expenditure on health falls short of what is needed for UHC, which limits the overall ‘ pie’ available for the PHC share and forces patients to continue to pay out-of-pocket, posing a persistent barrier to access. PHC should be free at the point of use because even small payments can deter use. This requires progressive removal of user fees and increased public funding. Increasing funding will be challenging in the near-future because of the economic impact of the COVID-19 pandemic, which will constrain government budgets.•Generating additional pooled resources is a challenge: fiscal capacity remains limited by macroeconomic conditions and inefficient revenue collection; however, additional resources will have to come mainly from taxes ( general or earmarked); expansion of social health insurance, a strategy being pursued in many low-income to middle-income countries, is constrained by the small size of the formal labour force in many countries; thus donors continue to have an important role to play in low-income settings.•Increasing tax revenue is both a technical issue ( how to increase tax capacity and how to broaden the tax base) and a political issue ( due to acceptability and compliance): the latter requires skilful engagement in budget politics.•Better spending of available resources is key, although the potential to generate efficiency savings in the health sector is limited within existing institutional arrangements; it also takes time ( and often investment) to achieve these savings.•Better pooling arrangements are also needed to reduce fragmentation, secure equitable cross-subsidies and efficient integration between levels of care. Where actual pooling is not possible, intermediate pooling supported by, for example, harmonisation of financing arrangements across pools, or virtual pools supported by digital technologies, can provide intermediate solutions.
•Government expenditure on health falls short of what is needed for UHC, which limits the overall ‘ pie’ available for the PHC share and forces patients to continue to pay out-of-pocket, posing a persistent barrier to access. PHC should be free at the point of use because even small payments can deter use. This requires progressive removal of user fees and increased public funding. Increasing funding will be challenging in the near-future because of the economic impact of the COVID-19 pandemic, which will constrain government budgets.•Generating additional pooled resources is a challenge: fiscal capacity remains limited by macroeconomic conditions and inefficient revenue collection; however, additional resources will have to come mainly from taxes ( general or earmarked); expansion of social health insurance, a strategy being pursued in many low-income to middle-income countries, is constrained by the small size of the formal labour force in many countries; thus donors continue to have an important role to play in low-income settings.•Increasing tax revenue is both a technical issue ( how to increase tax capacity and how to broaden the tax base) and a political issue ( due to acceptability and compliance): the latter requires skilful engagement in budget politics.•Better spending of available resources is key, although the potential to generate efficiency savings in the health sector is limited within existing institutional arrangements; it also takes time ( and often investment) to achieve these savings.•Better pooling arrangements are also needed to reduce fragmentation, secure equitable cross-subsidies and efficient integration between levels of care. Where actual pooling is not possible, intermediate pooling supported by, for example, harmonisation of financing arrangements across pools, or virtual pools supported by digital technologies, can provide intermediate solutions.
The Commission has not taken a position on a target spending level for health. That topic has been considered by various bodies that have each proposed their own benchmarks.63WHOThe Abuja declaration: ten years on. WHO, Geneva2010Google Scholar, 64WHO Commission on Macroeconomics and HealthMacroeconomics and health: investing in health for economic development/report of the commission on macroeconomics and health. WHO, Geneva2001Google Scholar, 65Jamison DT Summers LH Alleyne G et al.Global health 2035: a world converging within a generation.Lancet. 2013; 382: 1898-1955Google Scholar, 66WHOSustainable development goals: Health price tag.https: //www.who.int/news-room/q-a-detail/sustainable-development-goals-health-price-tagDate: July 17, 2017Date accessed: July 3, 2021Google Scholar, 67McIntyre D Meheus F Fiscal space for domestic funding of health and other social services. Chatham House, London2014Google Scholar Various governments and donors have committed to these benchmarks, although few have ever actually met the targeted spending level. Regardless of which benchmark is considered, LMIC governments and donors do not yet spend enough on health.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar These benchmarks might be useful for advocacy purposes, and to give a global indication of how much is needed overall. However, they do not recognise that a given level of spending could be necessary but not sufficient to achieve desired outcomes. The benchmarks also disregard the substantial variation in performance across countries with similar levels of government budget allocation to health.68Jowett M Brunal MP Flores G Cylus J Spending targets for health: no magic number. WHO, Geneva2016Google Scholar Whatever the benchmark, estimates of resources required should be based on per-capita needs rather than simply funding facilities or infrastructure.
The existing mechanisms for mobilising and pooling health funds in LMICs have multiple weaknesses that arise from their fragmented and insufficient revenue sources and the inherent challenges of pooling and managing resources. There are several specific problems.
The first is limited tax revenues. Public spending, including on health budgets, is often constrained by the general macroeconomic conditions and underlying weaknesses in national systems of taxation that limit the revenue base for public spending ( as shown by the low mean tax–GDP ratio in low-income countries of 12%, as compared with nearly 30% in high-income countries).69International Monetary FundWorld Revenue Longitudinal Data ( WoRLD).July 2021 ed. International Monetary Fund, Washington, DC, WA2021Google Scholar
The second is social health insurance contributions. Social health insurance contributions represent an important source of health funding in several high-income countries.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar However, the formal labour force in many LMICs is insufficient to support expanding social health insurance contributions; in low-income countries, for example, only 10·2% of the population works in the formal labour sector.70International Labour OrganizationWorld employment and social outlook. International Labour Organization, Geneva2020Google Scholar The COVID-19 pandemic has increased unemployment in the formal sector, with ever more workers shifting to the informal sector where it is more difficult to collect contributions.70International Labour OrganizationWorld employment and social outlook. International Labour Organization, Geneva2020Google Scholar Furthermore even when social health insurance contributions are collected, translating them into additional revenue for health is made complicated by the issue of fungibility ( interchangeability) within government budgets.
Third, a larger government budget does not necessarily lead to greater allocation to health. Even when governments do manage to expand the total envelope of available funds, either through tax revenues, social health insurance contributions, or donor financing, this does not necessarily lead to greater allocations to health.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar Failure to prioritise funding for health in total government spending might be due to technical issues ( such as insufficient capacity within ministries of health to present strong investment cases for health to ministries of finance).71Doherty J Kirigia D Okoli C et al.Does expanding fiscal space lead to improved funding of the health sector in developing countries? Lessons from Kenya, Lagos State ( Nigeria) and South Africa.Glob Health Action. 2018; 111461338Google Scholar It might also arise from public finance management structures that are not aligned with health budgeting needs or as a consequence of various political economy factors such as power imbalances and low levels of accountability between health system users and political leaders, and lobbies promoting other public expenditure priorities ( see section 6).
The fourth problem is inadequate, declining, and fragmented donor funding. Donor funding for health, although valuable and, for the foreseeable future, essential for low-income countries, has been falling since 2015·33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar The economic effects of the COVID-19 pandemic are likely to also negatively affect donors ' budgets. For example, in 2021, the UK Government reduced its international aid spending target from 0·7% of gross national income to 0·5%. Furthermore, donor development funding can be unpredictable even in good economic times as it is based on donor preferences. The funding that is made available is typically largely targeted to specific disease programmes ( in low-income countries, for example, an average of 65% of donor assistance is allocated to infectious and parasitic diseases).33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar, 72World BankHigh-performance health financing for universal health coverage: Driving sustainable, inclusive growth in the 21st century. World Bank, Washington, DC, WA2019Google Scholar Further, donor contributions tend to operate off-budget, undermining countries ' ability to plan and manage these resources alongside domestic funding.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar, 72World BankHigh-performance health financing for universal health coverage: Driving sustainable, inclusive growth in the 21st century. World Bank, Washington, DC, WA2019Google Scholar Nevertheless multilateral and bilateral assistance for selected low-income countries remains essential to at least 2030, and an improved global system of multilateral country support is required.
The fifth is excessive reliance on out-of-pocket spending. As alluded to previously, and as a result of the difficulty in raising pooled public funding, out-of-pocket payments by individuals are the dominant source of funding for health in low-income countries: they represent, on average, more than 40% of all health spending across all LMICs, and nearly 60% in the 32 low-income countries.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar Out-of-pocket payments can include formal user fees, informal fees levied by individual providers, travel costs, and payments for medicines and other supplies. Because payments made out of pocket are not pooled, they curtail cross-subsidisation between rich and poor, as well as between healthy and sick populations. The global health and economics communities have stated unequivocally that out-of-pocket payments need to be reduced ( and user fees for PHC removed) and instead replaced with prepaid and pooled funding.73WHOThe world health report: health systems financing: the path to universal coverage. WHO, Geneva2010Google Scholar Indeed, formal and informal user fees act as barriers ( disincentives) to accessing PHC, particularly for the poorest; for those who do choose to pay, user fees can lead to financial hardship.74James CD Hanson K McPake B et al.To retain or remove user fees? Reflections on the current debate in low- and middle-income countries.Appl Health Econ Health Policy. 2006; 5: 137-153Google Scholar, 75Gilson L McIntyre D Removing user fees for primary care in Africa: the need for careful action.BMJ. 2005; 331: 762-765Google Scholar The frequent argument that fees paid at the time of service prevent frivolous use of health services without causing harm is not substantiated by existing evidence.76Yates R Universal health care and the removal of user fees.Lancet. 2009; 373: 2078-2081Google Scholar Requiring even small payments can dramatically reduce use of highly cost-effective interventions.77The Abdul Latif Jameel Poverty Action LabThe impact of price on take-up and use of preventive health products.https: //www.povertyactionlab.org/policy-insight/impact-price-take-and-use-preventive-health-productsDate: 2018Date accessed: July 16, 2021Google Scholar User fee exemptions for the poor and vulnerable can mitigate access barriers, although experience in LMICs suggests they can be challenging to implement, as it is hard to identify the poor effectively and the criteria are often gamed or applied inconsistently.78Hanson K Worrall E Wiseman V Targeting services towards the poor: a review of targeting mechanisms and their effectiveness.in: Bennett S Gilson L Mills A Health, Economic Development and Household Poverty: From Understanding to Action. Routledge, London2007Google Scholar
The sixth is reduced budgetary allocations to health due to the economic impacts of COVID-19. Budget allocations to health were falling in LICs and lower-middle-income countries even prior to the COVID-19 pandemic.33WHOGlobal spending on health 2020: weathering the storm. WHO, Geneva2020Google Scholar As the COVID-19 emergency phase ends, many countries can be expected to experience falling government budgets.29Kurowski C Evans DB Tandon A et al.From Double Shock to Double Recovery. World Bank, Washington, DC, WA2021Google Scholar For example, the South African Health 2021 Medium Term Expenditure Framework budget was reduced by almost 10% over one budget cycle as a result of the post-COVID budgetary restrictions.79National Treasury of South AfricaBudget review 2021. South African National Treasury, Pretoria2021Google Scholar Austerity budgets following previous crises have had very harmful effects on health budgets.80WHOSpending on health in Europe: entering a new era. WHO Regional Office for Europe, Copenhagen2021Google Scholar
The seventh is difficulty in pooling resources. The incremental nature of UHC expansion often leads to the development of multiple risk pools as different programmes evolve to cover different population groups.81Reich MR Harris J Ikegami N et al.Moving towards universal health coverage: lessons from 11 country studies.Lancet. 2016; 387: 811-816Google Scholar Fragmentation of revenue streams is also an obstacle to pooling, with general tax revenues collected and used through the budget system and often disbursed as input-based budgets to maintain the health delivery infrastructure, and other sources of revenue pooled in an off-budget fund ( such as a public insurer) and disbursed as payments for services. Once multiple pools have been established, it can be politically difficult to merge or integrate them, as this requires trade-offs with some interest groups losing, or perceiving to lose, their advantages.
The convergence of these problems in mobilising and pooling funds for health has resulted in large variations in levels of government health spending, even among countries with similar economic status ( appendix p 12).
The Commission's vision for people-centred financing of PHC requires an adequately financed health sector funded by expanded public and pooled sources that protects people from financial hardship when seeking care and promotes equity.
Achieving the Commission's vision involves reducing out-of-pocket payments ( including removal of user fees for PHC) and replacing them with other types of pooled public funds that are raised through progressive means. In line with progressive universalism, the Commission argues for an explicit focus on addressing inequities.82WHOMaking fair choices on the path to universal health coverage: final report of the WHO consultative group on equity and universal health coverage. WHO, Geneva2014Google Scholar
One of the greatest sources of increased government health expenditure has been economic growth, rooted in conducive macroeconomic conditions.83Tandon A Cain J Kurowski C Dozol A Postolovska I From slippery slopes to steep hills: contrasting landscapes of economic growth and public spending for health.Soc Sci Med. 2020; 259113171Google Scholar However, in the near term this is unlikely to be sufficient to secure the additional financing needed due to the adverse global economic outlook generated by the COVID-19 pandemic. Below, we discuss other strategies for mobilising new public resources for health and investigate how countries can translate increased general revenue into increased funding for health. We also comment on the potential for the health sector to improve the efficiency of spending of its existing resources.
Governments and health systems have several options for increasing resources for health, including expanding taxation, expanding social health insurance contributions, and increasing borrowing.
The primary means of expanding resources for health in LMICs is to expand the overall available government revenue collected via taxation. This can entail improving collection of existing taxes, increasing the tax base, and expanding the number and types of taxes levied. LMICs, however, face significant challenges when collecting tax revenues. Constraints including lack of infrastructure ( including information technology systems) and administrative challenges, such as incomplete property registers, the size of the informal economy, or the inability to trace transactions within it. These limit the capacity of tax agencies, often already weakened by an insufficient number of skilled staff and limited technical capacities.
Expanding LMICs ' national taxation capacity therefore requires strengthening various institutions, systems, and skills. Countries also need to decide on the appropriate mix of direct ( income), indirect ( for example value-added tax) and other taxes ( including trade taxes), in which there will be a trade-off between administrative complexity and equity. Income taxes can be more progressive than indirect taxes, but require more elaborate systems to enforce compliance.84Besley T Persson T Why do developing countries tax so little?.J Econ Perspect. 2014; 28: 99-120Google Scholar More global comparative data on taxation across countries is now available than ever before and is vastly better than what was available 10 years ago.85Organisation for Economic Co-operation and DevelopmentGovernment at a Glance 2021. Organisation for Economic Co-operation and Development, Paris2021Google Scholar
LMICs could also focus on taxes that directly effect health outcomes, which are often perceived as politically more acceptable.86Cashin C Sparkes S Bloom D Earmarking for health: from theory to practice. WHO, Geneva2017Google Scholar The health sector is increasingly active in advocating for health taxes or excise taxes on unhealthy products such as tobacco, alcohol, and sugar-sweetened beverages. However, the primary purpose of these taxes is to improve population health status by creating disincentives to the use of harmful products. Therefore, where excise taxes are successful, they should eventually result in reduced revenue. However, in the meantime, these can raise revenue that can be earmarked for health if political economy considerations and budgetary rules are aligned.87Elliott LM Dalglish SL Topp SM Health taxes on tobacco, alcohol, food and drinks in low- and middle-income countries: a scoping review of policy content, actors, process and context.Int J Health Policy Manag. 2020; 11: 1-15Google Scholar According to the World Bank, an increase in excise taxes on tobacco, alcohol, and sugar-sweetened beverages that would result in a 50% increase in prices could raise the tax–GDP ratio by an average of 0·7 percentage points in low-income countries and LMICs.72World BankHigh-performance health financing for universal health coverage: Driving sustainable, inclusive growth in the 21st century. World Bank, Washington, DC, WA2019Google Scholar Other taxes could also be explored for the health sector, such as taxes on transport and airline levies88Mathauer I Koch K Zita S et al.Revenue-raising potential for universal health coverage in Benin, Mali, Mozambique, and Togo.Bull World Health Organ. 2019; 97: 620-630Google Scholar or on carbon emissions.72World BankHigh-performance health financing for universal health coverage: Driving sustainable, inclusive growth in the 21st century. World Bank, Washington, DC, WA2019Google Scholar Overall, the potential additional revenue that these taxes or levies could bring seems to be limited ( up to a maximum of 2·3% of actual spending on health).89Barroy H Sparkes S Dale E Mathonnat J Can low-and middle-income countries increase domestic fiscal space for health: a mixed-methods approach to assess possible sources of expansion.Health Syst Ref. 2018; 4: 214-226Google Scholar Earmarking these taxes to cover health expenditure is possible29Kurowski C Evans DB Tandon A et al.From Double Shock to Double Recovery. World Bank, Washington, DC, WA2021Google Scholar although it might be resisted, particularly by finance ministries,86Cashin C Sparkes S Bloom D Earmarking for health: from theory to practice. WHO, Geneva2017Google Scholar because of the inflexibility it introduces into the budgeting and planning process.
A tax on payroll, or compulsory social health insurance ( rather than voluntary as is the case of many community-based health insurance schemes) is also used as an earmarked tax for health. Indeed, many countries are working towards UHC through expansion of social health insurance,90Yazbeck AS Savedoff WD Hsiao WC et al.The case against labor-tax-financed social health insurance for low- and low-middle-income countries.Health Aff. 2020; 39: 892-897Google Scholar as it holds the potential to improve equity by increasing pooling and introducing pre-payment.91van Hees SGM O'Fallon T Hofker M et al.Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review.Int J Equity Health. 2019; 18: 134Google Scholar However, empirical evidence raises some concerns about the introduction of compulsory health insurance contributions in low-income countries.92Wagstaff A Social health insurance reexamined.Health Economics. 2010; 19: 503-517Google Scholar First, the necessary conditions for raising additional social health insurance funding are seldom met because most do not have full ( or nearly full) employment and few jobs are located in the formal sector, registered, and therefore taxable.90Yazbeck AS Savedoff WD Hsiao WC et al.The case against labor-tax-financed social health insurance for low- and low-middle-income countries.Health Aff. 2020; 39: 892-897Google Scholar Second, social health insurance might not be feasible due to the high costs of setting up and administering the collection of contributions92Wagstaff A Social health insurance reexamined.Health Economics. 2010; 19: 503-517Google Scholar and might take a long time to lead to the achievement of UHC, as was the case in Germany for example.93Busse R Blümel M Knieps F Bärnighausen T Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition.Lancet. 2017; 390: 8828982-9-8828982-17Google Scholar Whether the revenue raised can outweigh the operational costs has seldom been analysed.94Friebel R Josephson E Forman R Calza S Challenges of social health insurance in low- and lower-middle income countries: balancing limited budgets and pressure to provide universal health coverage.https: //www.cgdev.org/blog/challenges-social-health-insurance-low-and-lower-middle-income-countries-balancing-limitedDate: 2020Date accessed: June 4, 2021Google Scholar When it has been examined, the findings are inconclusive.90Yazbeck AS Savedoff WD Hsiao WC et al.The case against labor-tax-financed social health insurance for low- and low-middle-income countries.Health Aff. 2020; 39: 892-897Google Scholar Third, the cost to employers of social health insurance premiums might also have a negative effect on the labour market, reducing the probability of employment in the formal sector as well as wages.95Baicker K Chandra A The labor market effects of rising health insurance premiums.Journal of Labor Economics. 2006; 24: 609-634Google Scholar The changing nature of work, including demographic changes and structural changes in employment, pose a challenge to the feasibility and sustainability of mobilising resource for health through employment-based models such as social health insurance.96World BankWalking the talk: reimagining PHC after COVID-19. World Bank, Washington, DC, WA2021Google Scholar Finally, social health insurance does not necessarily support progressive universalism, as it can redistribute resources towards wealthier segments of the population. For example, general revenues can be used to subsidise social health insurance that predominantly serves upper-income groups rather than ensuring that subsidies are used to extend coverage to vulnerable segments of the population.90Yazbeck AS Savedoff WD Hsiao WC et al.The case against labor-tax-financed social health insurance for low- and low-middle-income countries.Health Aff. 2020; 39: 892-897Google Scholar
Whatever tax is chosen, political economy factors, both internal and external, as well as the structure of LMIC economies, always threaten the feasibility of taxation reforms ( panel 6).Panel 6Political economy challenges of expanding taxation in low-income to middle-income countries ( LMICs) An increase in taxes is never welcomed by taxpayers. Introducing taxation reforms involves complex political economy concerns, including: Internal factorsTaxation reform involves extensive bargaining among different actors, including governments, taxpayers, specific industries and sectors, tax intermediaries such as accountants and tax advisers, and revenue collection organisations.97Moore M Obstacles to increasing tax revenues in low income countries. Institute of Development Studies, Brighton2015Google Scholar As such, the process of bargaining with all stakeholders will be central to decisions about the design of tax regimes. Certain groups might be disproportionately affected by different taxes—and this might constrain the feasibility of adopting them. For instance, although a property tax could be an effective way to increase tax revenue, these tend to affect wealthier people who are closely connected with political decision makers.98Mills L Barriers to increasing tax revenue in developing countries. Institute of Development Studies, Brighton2017Google Scholar Similarly, sugar-sweetened beverage taxes, although important for chronic diseases, affect particular agricultural and industrial sectors.External factorsLMICs ' ability to raise taxation revenue is currently substantially limited by existing bilateral tax treaties and the associated curtailment of taxes on multinational companies, tax evasion and avoidance, loss of potential revenue from extractive industries, and tax exemptions and incentives given to investors.98Mills L Barriers to increasing tax revenue in developing countries. Institute of Development Studies, Brighton2017Google Scholar The G20 finance ministers ' recent announcement of a minimum 15% tax on multinationals in countries where they operate is a positive step towards addressing this issue.99Organisation for Economic Co-operation and DevelopmentOECD secretary-general tax report to G20 finance ministers and central bank governors–July, 2021. Organisation for Economic Co-operation and Development, Paris2021Google ScholarStructure of the economyLMICs typically have a large informal sector which is difficult to tax. Further, the economy might be comprised of many small-scale firms that are more likely to be dependent on a few natural resources or commodities. LMIC economies also often rely on foreign aid, which is not taxable. These factors limit tax collection and the tax base.84Besley T Persson T Why do developing countries tax so little?.J Econ Perspect. 2014; 28: 99-120Google Scholar
An increase in taxes is never welcomed by taxpayers. Introducing taxation reforms involves complex political economy concerns, including:
Taxation reform involves extensive bargaining among different actors, including governments, taxpayers, specific industries and sectors, tax intermediaries such as accountants and tax advisers, and revenue collection organisations.97Moore M Obstacles to increasing tax revenues in low income countries. Institute of Development Studies, Brighton2015Google Scholar As such, the process of bargaining with all stakeholders will be central to decisions about the design of tax regimes. Certain groups might be disproportionately affected by different taxes—and this might constrain the feasibility of adopting them. For instance, although a property tax could be an effective way to increase tax revenue, these tend to affect wealthier people who are closely connected with political decision makers.98Mills L Barriers to increasing tax revenue in developing countries. Institute of Development Studies, Brighton2017Google Scholar Similarly, sugar-sweetened beverage taxes, although important for chronic diseases, affect particular agricultural and industrial sectors.
LMICs ' ability to raise taxation revenue is currently substantially limited by existing bilateral tax treaties and the associated curtailment of taxes on multinational companies, tax evasion and avoidance, loss of potential revenue from extractive industries, and tax exemptions and incentives given to investors.98Mills L Barriers to increasing tax revenue in developing countries. Institute of Development Studies, Brighton2017Google Scholar The G20 finance ministers ' recent announcement of a minimum 15% tax on multinationals in countries where they operate is a positive step towards addressing this issue.99Organisation for Economic Co-operation and DevelopmentOECD secretary-general tax report to G20 finance ministers and central bank governors–July, 2021. Organisation for Economic Co-operation and Development, Paris2021Google Scholar
LMICs typically have a large informal sector which is difficult to tax. Further, the economy might be comprised of many small-scale firms that are more likely to be dependent on a few natural resources or commodities. LMIC economies also often rely on foreign aid, which is not taxable. These factors limit tax collection and the tax base.84Besley T Persson T Why do developing countries tax so little?.J Econ Perspect. 2014; 28: 99-120Google Scholar
Generating additional resources from taxes, including for health, is certainly possible—but it requires a tailored strategy in each country and it takes time. Developing a tax reform strategy requires understanding the types of taxes and rates that are feasible given the political and economic structure of a country, and a whole-of-government effort to successfully push to increase the overall revenue envelope. For example, Tunisia increased its tax revenue from 18·2% of GDP in 1990, to 32·1% in 2018.100Organisation for Economic Co-operation and DevelopmentRevenue Statistics in Africa 2020, Tunisia.https: //www.oecd.org/countries/tunisia/revenue-statistics-africa-tunisia.pdfDate: 2020Date accessed: July 20, 2021Google Scholar It is now nearly double the average of 16·5% across Africa in 2018.101Organisation for Economic Co-operation and DevelopmentStrengthening tax capacity to increase domestic resources in Tunisia. Organisation for Economic Co-operation and Development, Paris2021Google Scholar This was achieved through the implementation of multiple policies, including: countering harmful tax practices, preventing tax treaty abuse, making dispute resolution mechanisms more effective, tackling money laundering, and cracking down on tax evasion. Aside from the technical solutions that were adopted, political resolve was essential in driving these reforms, and their success.100Organisation for Economic Co-operation and DevelopmentRevenue Statistics in Africa 2020, Tunisia.https: //www.oecd.org/countries/tunisia/revenue-statistics-africa-tunisia.pdfDate: 2020Date accessed: July 20, 2021Google Scholar, 101Organisation for Economic Co-operation and DevelopmentStrengthening tax capacity to increase domestic resources in Tunisia. Organisation for Economic Co-operation and Development, Paris2021Google Scholar
Another way to increase the budget available for health is to use government borrowing, as a short term approach. In times of crisis, government borrowing can have an important temporary role in sustaining health and social spending. The ongoing global COVID-19 pandemic, and the associated global recession represent just such a situation. Some reflections on the challenges of mobilising revenue in times of crisis are presented in the appendix ( p 3). Deficit financing is typically considered more suitable for capital, rather than recurrent, expenditures. However, it can have a crucial role in supporting countries to emerge from crises while helping to mitigate their social consequences. In the first quarter of 2021, the International Monetary Fund, World Bank, and OECD all called on countries to take on temporary debt to finance human development. These institutions have emphasised the important role of the health sector in dealing with the pandemic, as well as in turning around the COVID-19-induced economic crisis. They also note the importance of not withdrawing social support, health spending, or fiscal stimulus in the midst of a pandemic.102International Monetary FundFiscal monitor: A fair shot. International Monetary Fund, Washington, DC, WA2021Google Scholar
The increased borrowing will need to be accommodated by fiscal adjustments in the future. Most countries are projected to go through extended periods of fiscal adjustments in the coming years; in some places, the overall government spending envelope is expected to shrink, as will discretionary spending as a share of government expenditures, as debt service requirements grow.29Kurowski C Evans DB Tandon A et al.From Double Shock to Double Recovery. World Bank, Washington, DC, WA2021Google Scholar Grants, concessionary loans, and favourable debt treatment, including debt service suspension and restructuring, will be vital for many LMICs in the coming months and years. Government debt can help maintain liquidity and solvency and support to the spending needed to recover from COVID-19. Although LMIC governments might be reluctant to acquire more debt, it represents a way to respond to crises while expanding support for the health sector. Ultimately, investing in health will benefit the economy, enabling countries to get out of debt more quickly.
Another way to increase the overall envelope is by bringing donor funding on-budget and aligning it with national priorities. The COVID-19 pandemic ( just as with the 2016 Ebola epidemic) showed that investing in health in LMICs has global significance.29Kurowski C Evans DB Tandon A et al.From Double Shock to Double Recovery. World Bank, Washington, DC, WA2021Google Scholar Donor funds not only need to increase, but they also need to be used in ways that align with government priorities, after the principles of the Paris Declaration.103Organisation for Economic Co-operation and DevelopmentThe Paris declaration on aid effectiveness: five principles for smart aid. Organisation for Economic Co-operation and Development, Paris2005Google Scholar
Whichever strategies are selected by governments, and specifically ministries of finance, to secure additional resources, the next step is to ensure that the new resources are invested in health. The widespread economic impact of the COVID-19 pandemic has provided clear evidence of the close connection between health and economic prosperity and should strengthen the case for increased investment in health. However, ensuring that adequate resources are allocated to health requires continuous efforts. The allocation of resources to health is an intensely political issue. Multiple political economy factors have a role in whether health is prioritised.
The first factor is competing demands. In the face of infinite needs, different sectors in a given country must compete for limited funds. How much goes to health depends both on how much value is placed on health and on what other challenges the country faces. A country struggling with active conflict might prioritise military spending over health. For example, Mali's budget allocation to health decreased from 2016 in the face of a domestic terrorist insurgency.47WHOGlobal health expenditure database.https: //apps.who.int/nha/databaseDate: 2021Date accessed: August 3, 2021Google Scholar, 104Global financing facilityDossier d'investissement de la sante de la reproduction, de la mere, du nouveau-ne, de l'adolescent et de la nutrition ( SRMNEA + N2019-2023). Global Financing Facility, 2021https: //www.globalfinancingfacility.org/mali-investment-case-reproductive-maternal-child-adolescent-health-and-nutrition-2019-2023-frenchDate accessed: December 8, 2021Google Scholar Health advocates must both understand the competing demands and determine how best to present health as an economically sound and ethical investment.
The second is who benefits from funding health. In most countries, small elite groups of politicians and financiers wield the most control over budgeting and financing decisions. Unless they see benefits in investing in health, little might change. In Turkey, for example, there were nine unsuccessful attempts to establish a national health insurance system for UHC before 2003. Those attempts were blocked in part by legislative gridlock in the parliament and opposition to new legislation by the Constitutional Court.105Sparkes SP Bump JB Reich MR Political strategies for health reform in Turkey: extending veto point theory.Health Systems Reform. 2015; 1: 263-275Google Scholar UHC was eventually adopted after the rise of the AK party, whose platform centred, at the time, on opposition to persistent inequalities106Baris E Mollahaliloglu S Aydin S Healthcare in Turkey: from laggard to leader.BMJ. 2011; 342c7456Google Scholar ( see section 6 for further details).
Third is that in certain contexts, health must become part of a popular political agenda in order to be prioritised. This can occur during political transitions, such as following the fall of dictatorships,55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar, 107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar the rise to power of an insurgency ( as in Ethiopia),108Croke K The origins of Ethiopia's PHC expansion: the politics of state building and health system strengthening.Health Pol Plan. 2020; 35: 131-227Google Scholar or as a result of crisis such as COVID-19 ( see section 6 for further details).
Whilst this list is by no means exhaustive, it illustrates the need to take political economy considerations into account in tandem with technical solutions to gain support for health.
Whether or not total health spending increases, a shift from out-of-pocket spending towards pooled arrangements can radically improve the equity and efficiency of health financing.
A defining characteristic of the health sector is the high degree of uncertainty associated with health needs, which vary across populations, over time, and across geographies. This uncertainty makes it necessary to pool risk across populations to protect individuals from financial hardship if they find themselves in the unlucky group that requires expensive health services. Redistribution of resources from people and places of lower need to those of higher need is more effective in larger, more diverse pools. Pooling can occur either in government budgets ( at central or decentralised levels), through compulsory insurance schemes, or, potentially, through virtual health insurance pools supported by digital technologies. The opportunities, and challenges, of virtual pools are discussed in the appendix ( p 34). Many countries are moving in the direction of merging or consolidating multiple pools to gain the benefits of more effective risk-pooling, which include better redistributive mechanisms and greater equity, stronger purchasing power, and increased administrative efficiency.109Mathauer I Digital technologies for health financing: what are the benefits and risks for UHC? Some initial reflections. WHO, Geneva2021Google Scholar
Inefficiencies in health spending exist. The 2010 World Health Report stated that there were inefficiencies equivalent to 20–40% of health spending, and in the OECD between 20% and 50% of health expenditures might be wasted due to inefficiencies.73WHOThe world health report: health systems financing: the path to universal coverage. WHO, Geneva2010Google Scholar, 110Organisation for Economic Co-operation and DevelopmentTackling Wasteful Spending on Health. Organisation for Economic Co-operation and Development, Paris2017Google Scholar Inefficiency can be allocative ( that is, spending money on the wrong interventions, such as high-cost, low-impact health services). Inefficiency can also be technical ( failing to get the maximum output from available inputs, for example when patented drugs are purchased in lieu of generic drugs). In theory, addressing these inefficiencies could be a source of resources available to the health sector by releasing resources while maintaining ( or even increasing) output. Efficiency can also improve if greater outcomes are achieved with the same inputs; however, this does not increase fiscal space. Efficiency reforms should not be seen as a way to either balance budgets or identify spending cuts in health. However, they do form part of the wider effort to use available health resources to improve health outcomes, and to persuade ministries of finance to increase the health budget.
Improving either technical or allocative efficiency is a complex task, fraught with technical and political hurdles, and requiring time. A review done for this Commission111London School of Hygiene and Tropical MedicineTechnical team. Systematic review of inefficiencies in financing PHC.https: //www.lshtm.ac.uk/financing-phcDate: 2021Date accessed: December 6, 2021Google Scholar showed that the efficiency gains that could be achieved in practice through reforms addressing inefficiencies are likely to be smaller in magnitude than suggested in the 2010 World Health Report.73WHOThe world health report: health systems financing: the path to universal coverage. WHO, Geneva2010Google Scholar Furthermore, the available evidence on the timing and feasibility of efficiency-focused reforms is scarce and not generalisable across countries. The methods used for the literature review, together with an overview of possible efficiency reforms identified, are presented in the appendix ( p 37).
Although the effect of some reforms focused on enhancing spending efficiency might be immediate ( such as requiring the purchase of generic rather than branded medicines, or use of bulk tenders for medicines or medical equipment), many others may take years to reap benefits. Many inefficiencies, such as leakage due to corruption or fraud, are structural; tackling them requires addressing historical precedents and social norms in addition to administrative processes.112World BankBackground paper for second annual UHC financing forum: Greater efficiency for better health and financial protection.https: //thedocs.worldbank.org/en/doc/5d7befa83cbafe469a1f9a5d591eb443-0140062021/related/Background-Paper-Second-Annual-UHC-Financing-Forum-FORUM.pdfDate: 2017Date accessed: July 18, 2021Google Scholar Further, it should be noted that addressing some inefficiencies can require upfront investments. This might be one area where digital technologies can prove ( positively) disruptive, as long as they do not create new fragmentation ( appendix p 16).
Finally, although the focus here has been on whether inefficiencies could lead to financial savings ( as has been argued by many finance ministers), ministries of health should be working to improve the value for money of their spending. This outcome might be realised through a decrease in cost, as long as the outcome ( including quality of care) remains the same. It might also involve an increase in cost with an accompanying improvement in outcomes or simply an improvement in outcomes, with the cost remaining constant.
The need to shift away from out-of-pocket spending towards pooled public funding is urgent, yet the reforms to increase resource mobilisation and pooling necessary to achieve this objective will take time to design and implement. Investments in strengthening the tax base, expanding the types of taxes levied, and tax collection capacity—all of which fall outside the purview of the ministry of health—will be essential. Digital technologies might hold some promise ( for example through virtual pools), although caution is warranted in ensuring that these align with UHC objectives. Improving the efficiency of spending can help, but is not the primary way to create more fiscal space for health.
In the Commission's vision, each country's health sector strategically uses appropriate policy tools to direct sufficient resources to PHC to enable a universally accessible system that provides quality services in line with a benefit package appropriate to the level of care. To do so requires mechanisms for funding, budgeting, and financial management to ensure that those resources reach frontline providers and platforms. It will also organise the service delivery system to pull resources to PHC. By doing so, countries can support the delivery of, and equitable access to, people-centred PHC. Key messages from this section are presented in panel 7.Panel 7People-centred allocation of resources for primary health care ( PHC) –key messages•Increasing the allocation of health resources to PHC is a political decision; it might involve redistributing of resources—in absolute or relative terms—away from other sectors, or within the health sector away from hospitals.•Increasing budget allocations to PHC does not guarantee that resources reach frontline services; protecting PHC allocations to the point where they reach frontline providers requires clarity, active steering, and accountability mechanisms.•Making allocations to PHC more visible in health budgets is an important way to improve tracking of existing resources, secure additional resources, and highlight the importance of essential public health functions.•A range of policy levers are available to increase and protect allocations to PHC. Public finance management tools, particularly those that strengthen budget formulation and execution, can be used to increase PHC budgets, make them more visible in the public finance management system, and ensure that resources reach frontline services. Service delivery arrangements can be used to pull resources to PHC. These arrangements include explicit service standards and guidelines, new configurations of teams, and effective referral systems. In some instances, new cadres of frontline PHC providers have enabled more resources to be directed to PHC. All these improvements can have the effect of stimulating demand for PHC and, with the right financing arrangements, drawing more resources to this level.•Multiple tools can be applied at the same time. Many of them require a clear and context-specific operational definition of PHC. Applying public finance management levers requires engaging with various health and public finance management system capacities.•Institutional responsibility for PHC is typically fragmented across ministry of health departments; as a result no single unit is in charge of securing funding or held accountable for progress. Although it is not necessary to create a new operational unit for PHC to ensure that PHC is prioritised, it must be clear where responsibility for budgeting and planning for PHC lies in the ministry of health.
•Increasing the allocation of health resources to PHC is a political decision; it might involve redistributing of resources—in absolute or relative terms—away from other sectors, or within the health sector away from hospitals.•Increasing budget allocations to PHC does not guarantee that resources reach frontline services; protecting PHC allocations to the point where they reach frontline providers requires clarity, active steering, and accountability mechanisms.•Making allocations to PHC more visible in health budgets is an important way to improve tracking of existing resources, secure additional resources, and highlight the importance of essential public health functions.•A range of policy levers are available to increase and protect allocations to PHC. Public finance management tools, particularly those that strengthen budget formulation and execution, can be used to increase PHC budgets, make them more visible in the public finance management system, and ensure that resources reach frontline services. Service delivery arrangements can be used to pull resources to PHC. These arrangements include explicit service standards and guidelines, new configurations of teams, and effective referral systems. In some instances, new cadres of frontline PHC providers have enabled more resources to be directed to PHC. All these improvements can have the effect of stimulating demand for PHC and, with the right financing arrangements, drawing more resources to this level.•Multiple tools can be applied at the same time. Many of them require a clear and context-specific operational definition of PHC. Applying public finance management levers requires engaging with various health and public finance management system capacities.•Institutional responsibility for PHC is typically fragmented across ministry of health departments; as a result no single unit is in charge of securing funding or held accountable for progress. Although it is not necessary to create a new operational unit for PHC to ensure that PHC is prioritised, it must be clear where responsibility for budgeting and planning for PHC lies in the ministry of health.
The objective of resource allocation for PHC is to ensure that sufficient resources are directed to, and reach, frontline providers working in PHC platforms, including at community level, as well as supporting essential public health functions. Whether or not the overall fiscal space for health is increased, deliberate efforts can be made to allocate more resources to PHC from existing health budgets, either through the budget process or by strengthening budget execution to ensure that available resources for PHC effectively reach PHC platforms and providers.
Putting people at the centre of these arrangements entails allocating resources for PHC based on population needs, rather than allocating resources to facilities, inputs, or vertical programmes. To achieve equity in this allocation process means prioritising the needs of people with the lowest socioeconomic status and least-served geographic areas. This section of the report explores the forces that can draw resources away from PHC, and describes policies that support allocation and protection of resources for PHC. It also addresses the special case of allocating and securing financing for essential public health functions. We acknowledge that various other policies also indirectly influence allocations to PHC, including some key PHC design elements and how PHC is linked to higher levels of the health system. Provider payment methods, which are addressed in greater detail in section 5, are central to this.
Allocation of resources to health in general, and to PHC in particular, occurs in different ways in different systems of government. In centralised budget systems, the collection and allocation of funds takes place centrally with, typically, the Ministry of Finance allocating a set amount, based on multisectoral budget negotiations, to the Ministry of Health. Although some of these resources might be ring-fenced for specific purposes, many decisions about allocation within the health sector are the responsibility of the Ministry of Health. It decides how to allocate the available funds to geographic units ( such as provinces) or to levels or platforms of care, such as PHC.
In decentralised systems, decisions about resource allocation—across sectors and within the health sector—are made by local authorities. This gives the opportunity for resource allocation decisions to be shaped by local needs, disease patterns, and priorities. However, it can also lead to a focus on financing services that are popular or visible, rather than those that bring the greatest population health benefits. A key challenge for decentralised systems is that allocations to health in general, and PHC in particular, might be less visible and traceable at national level than when they are presented as part of a single centralised budget. Therefore, decentralised systems might require additional policy tools ( such as common budget structures and reporting systems) to protect, manage, and monitor the use of resources for PHC. The countries of Kenya, India, and the Philippines are all examples of devolved decentralised systems where allocations to, and power over, health are substantially determined at subnational level.
Whether a government is organised as a centralised or decentralised system represents a broader political choice that is made outside of the health sector. However, the health sector must adapt its allocation processes to match the wider political structure of the country.
As with allocations to health in general, there is no definitive answer about how much is the right amount to allocate to PHC in any given setting. The key issue is estimating the resources required to finance a PHC package that is universally accessible, places minimum financial burdens on users, and that is aligned to macrofiscal capacity. The analysis of the relationship between PHC spending and coverage of priority interventions presented in section 2 showed that there is substantial variation in the level of coverage achieved for a given spending level, particularly in LMICs; section 3 discussed some evidence about spending targets.
Costing exercises can help to inform these decisions. However, costing requires a clear operational understanding of what constitutes the PHC platform and services in that particular setting. South Africa has used numerous approaches to cost its PHC system, including normative personnel and infrastructure costing, modelling visit rates and unit costs, complex methods of costing specific disease groups and treatment interventions, comparisons of facilities using cost, efficiency, and quality indicators, and actuarial approaches in designing capitation payments.
Budget allocation processes are influenced by a range of political forces operating at all levels. Problems, such as those created by political patronage systems,113Manthalu G Nkhoma D Kuyeli S Simple versus composite indicators of socioeconomic status in resource allocation formulae: the case of the district resource allocation formula in Malawi.BMC Health Serv Res. 2010; 10: 6Google Scholar, 114Chee HL Ownership, control, and contention: challenges for the future of healthcare in Malaysia.Soc Sci Med. 2008; 66: 214-256Google Scholar can be exacerbated in decentralised systems where local political incentives, power relations, and special interests can carry more weight than the policy priorities of a central Ministry of Health. Vested interests at central level might also skew resource allocation.
PHC faces particular problems in attracting sufficient resources because it typically does not elicit strong political support within the health sector and may be excluded from the benefit package of particular insurance arrangements. Responsibility for elements of PHC might be fragmented across agencies or technical departments, with no clear responsibility or accountability for delivering on policy commitments to improve PHC.
Other factors combine to limit the political attractiveness of PHC. In particular, the people who would benefit most from expanding and improving PHC ( for example, children, women, and people living with chronic conditions) typically have little political power. Furthermore, when PHC is done well, it keeps people healthy and thus becomes nearly invisible.
In contrast, allocating resources to hospitals is more politically appealing. The hospital is a highly visible symbol of the health system. A hospital is the site of more, and more expensive, technology, which is perceived as beneficial and important. Hospitals also employ specialist physicians, who tend to have higher professional status and political connections than PHC workers. Hospitals engage in readily apparent medical education and other training activities, and employ large numbers of support staff. They tend to be located in urban areas, closer to decision makers, and cater to wealthier population groups who wield significant political influence.
Therefore, when limited resources are available for health, hospitals and other secondary and tertiary care initiatives are often more successful at securing them. However, this imbalance undermines the efficiency and equity of the health system as a whole. In this section, we simply note that the process of securing budgets for PHC is not merely technical but is also influenced by political forces. Section 6 addresses the political economy of financing PHC in much more detail.
A number of technical factors can also impede increased allocations to PHC or divert funds away from PHC. Addressing these is essential to protect resources for PHC and ensure they reach the frontline. This can be done through careful system design and, in particular, the use of various categories of policy tool ( figure 9).Figure 9Policy tools to increase and protect resource allocations to PHCShow full captionPHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
The first category of tools is related to budget formulation. Programme budgeting, budget rules and statutory appropriations, and conditional grants influence how budgets are made and aligned with policy priorities. A second category of tools relates to budget execution, or the effectiveness with which funds flow through the system. These include the use of population-based resource allocation formulae and direct facility funding. Some purchasing tools, such as benefit specification, provider payment, and contracting arrangements, also fall in this category because they influence the flow of funds. The third category concerns how PHC services are organised and how they relate to and interact with the rest of the health system. This category includes the adoption of an operational definition of PHC, the use of norms and standards to establish resource requirements, service delivery models, and effective referral and gatekeeping functions.
The first two categories, budget formulation and budget execution, are part of public finance management processes; for their part, service delivery arrangements will influence both the estimation of budget needs and the routes through which funds move through the health financing system. These policy levers clearly are not mutually exclusive; indeed, they can be undertaken in parallel. We outline a short overview of each of these levers in the following sections. The capacities ( of the health system and broader public finance management processes) required to deploy these tools are presented in the section's conclusion.
The primary instrument for allocating public funds to health programmes is the government budget. The budget formulation processes used by many governments can sit at odds with the unpredictability and complexity of resource needs for health,115WHOBuilding strong public financial management systems towards universal health coverage: key bottlenecks and lessons learnt Regional workshop on PFM for sustainable financing for health in Africa. WHO, Nairobi2018Google Scholar with budget formulation and stated policy objectives often disconnected.116Cashin C Bloom D Sparkes S Barroy H Kutzin J O'Dougherty S Aligning public financial management and health financing: sustaining progress toward universal health coverage. WHO, Geneva2017Google Scholar In practice, the process of budget formulation is commonly reduced to incremental adjustments to the previous year's budget. Health budgets also suffer from a lack of credibility, as they are often believed to be based on inaccurate data and incomplete budgeting analysis.117Simson R Welham B Incredible budgets: budget credibility in theory and practice. Overseas Development Institute, London2014Google Scholar Even when PHC is nominally prioritised in national policies and plans, budgeting structures and processes can inhibit the allocation and flow of funds to PHC providers. In most countries, PHC is not a visible line item in the national budget, making it hard both to pinpoint how much is being allocated and to monitor whether PHC funds are actually received. Instead, PHC budgets are often embedded in, and absorbed by, the budgets of hospitals or local governments. Budgets frequently follow a line-item structure, with resource flows tied to inputs rather than to activities, levels of care, or population health needs. In these systems, resources get to frontline PHC providers mostly through in-kind, easily quantified provision of medicines and supplies, and staff salaries. Establishing appropriate programme budgeting can help to make financial allocations to PHC more visible in the budget.
Oversight of resource allocation to PHC is especially complicated when multiple financing agents and purchasers are involved. This occurs, for example, if a social health insurance fund is administered separately from the government health budget. The social health insurance fund is then outside the influence of the ministry of health and different provider payment mechanisms might apply. Likewise, in decentralised systems, central authorities have little oversight or influence over budget allocations by decentralised authorities. In China, for instance, PHC is the responsibility of two different agencies: the local health bureau for essential public health services and the social insurance office for medical services. Each has a separate budget and uses different provider payment methods ( see section 5). In the Philippines, fragmented funding makes it difficult to prioritise PHC ( panel 8). As noted in section 3, donors can contribute to fragmentation of budgets when their substantial contributions remain off-budget and separate from national plans. Ethiopia provides an interesting example of a national initiative to harmonise all sources of funding on one budget, which is called One Health, One Plan, One Budget.118Woldie M Resource mobilisation and allocation for PHCPHC: lessons from the Ethiopian health system. London: Lancet Global Health commission on financing people-centred PHC.https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google ScholarPanel 8Multiple funding flows and fragmented budgeting processes for primary health care ( PHC) in the Philippines ' decentralised systemThe Commission's case study on the Philippines examined the arrangements for funding PHC in a decentralised political system. Health is a devolved function in the Philippines: local governments receive a share of general tax revenue and are also able to raise revenue through local taxes. Decisions about the allocation of these funds between health and other sectors are taken at the municipal level. In addition to a share of these general funds, health receives some additional supply-side funding from the central government for infrastructure and for employment of essential staff. Local government also receives reimbursement for PHC from PhilHealth, the national social health insurance programme.Resources are allocated among sectors through a process that is led by the elected municipal mayors. Budget rules provide for mandatory shares of the budget to some sectors, such as gender and development, but no such rule is imposed for health. The local health plan is the instrument used to consolidate PHC funds from different sources. But priorities can diverge between political and technical participants.The fragmentation of PHC funding is exacerbated by the different timelines for the national and municipal planning cycles, and different procurement rules applied to different funding sources. In practice, reimbursement from PhilHealth is unpredictable due to administrative complexity; this revenue is also affected by low claims by beneficiaries who are unaware of their entitlements.The outcome of this process is that municipalities spend only 7% of their budget on health, against a benchmark of 15% set by the central health ministry. Two new initiatives under the Universal Health Coverage Act are intended to help consolidate and align resources for PHC: the development of a new primary care provider network, and a special health fund that is pooled at the province level. Local actors remain sceptical about whether these technical solutions can address the political issues of resource allocation.
The Commission's case study on the Philippines examined the arrangements for funding PHC in a decentralised political system. Health is a devolved function in the Philippines: local governments receive a share of general tax revenue and are also able to raise revenue through local taxes. Decisions about the allocation of these funds between health and other sectors are taken at the municipal level. In addition to a share of these general funds, health receives some additional supply-side funding from the central government for infrastructure and for employment of essential staff. Local government also receives reimbursement for PHC from PhilHealth, the national social health insurance programme.
Resources are allocated among sectors through a process that is led by the elected municipal mayors. Budget rules provide for mandatory shares of the budget to some sectors, such as gender and development, but no such rule is imposed for health. The local health plan is the instrument used to consolidate PHC funds from different sources. But priorities can diverge between political and technical participants.
The fragmentation of PHC funding is exacerbated by the different timelines for the national and municipal planning cycles, and different procurement rules applied to different funding sources. In practice, reimbursement from PhilHealth is unpredictable due to administrative complexity; this revenue is also affected by low claims by beneficiaries who are unaware of their entitlements.
The outcome of this process is that municipalities spend only 7% of their budget on health, against a benchmark of 15% set by the central health ministry. Two new initiatives under the Universal Health Coverage Act are intended to help consolidate and align resources for PHC: the development of a new primary care provider network, and a special health fund that is pooled at the province level. Local actors remain sceptical about whether these technical solutions can address the political issues of resource allocation.
Several policy levers are available to address these problems and strengthen budget formulation.
( 1) Programme budgets: this approach organises the budget according to programmes ( eg, a service or group of services) rather than by inputs.119Robinson M Last DP A basic model of performance-based budgeting. International Monetary Fund, Washington, DC, WA2009Google Scholar Programme or performance-based budgeting serves to clarify programme objectives, and improves monitoring and accountability, as each programme can also have associated performance measures.120Barroy H Blecher M Lakin J How to make budgets work for health: a practical guide to designing, managing and monitoring programme budgets in the health sector. WHO, Geneva2021Google Scholar, 121Abewe C Margini F Mwami E Mwoga J Kwesiga B Transition to programme budgeting in Uganda: status of the reform and prelimnary lessons for health. WHO, Geneva2021Google Scholar South Africa uses a programme-based budgeting approach alongside a higher-level item classification, and has a specific budget for PHC comprised of seven subprogrammes within the District Health Services programme, with substantial flexibility in shifting funds. This standardised programme structure applies across all provinces and districts. Each PHC facility can spend up to their budget limit in line with an agreed spending schedule. The five basic PHC subprogrammes ( clinics, community health centres, community based services, district management, and other community services) comprise 19·2% of total public health expenditure ( 31·1% when including the HIV or AIDS and PHC facilities subprogrammes). Budgeting for the PHC programme can be a means of creating greater visibility and protecting resources for PHC. When applied generally across a government, programme or performance-based budgeting seems to be effective in improving resource allocation to health and supporting more productive negotiations between the Ministry of Finance and line ministries. Input-based budgets maintained alongside programme budgets facilitate financial control.However, programme-budgeting requires both considerable budget management capacity within the spending institutions and good costing information. It might also lead to new rigidities in budget execution if controls are carried over from input-based budgeting.120Barroy H Blecher M Lakin J How to make budgets work for health: a practical guide to designing, managing and monitoring programme budgets in the health sector. WHO, Geneva2021Google Scholar, 122Rajan D Barroy H Stenberg K Strategizing national health in the 21st century: a handbook. Chapter 8: budgeting for health. WHO, Geneva2016Google Scholar Although there is scope for expanding programme-based budgeting, there is little experience in how to address specific demands of the health sector.123Barroy H Dale EM Sparkes S Kutzin J Budget matters for health: key formulation and classification issues. World Health Organization, Geneva2018Google Scholar Programme-based budgeting for PHC also assumes that the package of services, as well as the level at which given services are to be delivered, are defined. As outlined in section 2, this is a key challenge for policy makers. Although experience with programme budgets is growing, there is still much that needs to be tested.120Barroy H Blecher M Lakin J How to make budgets work for health: a practical guide to designing, managing and monitoring programme budgets in the health sector. WHO, Geneva2021Google Scholar ( 2) Budget rules and statutory appropriations: this is another approach to ensure sufficient budgets for PHC. Budget guidelines can mandate minimum budget shares for specific sectors ( as in the case of the gender and development sector in the Philippines; panel 7). Statutory appropriations are a legally-mandated standing budget provision ( so-called appropriation), which is not dependent on the passing of a legislative appropriation bill. For example, in Nigeria, the National Health Act earmarks 1% of the federal government's consolidated revenue to fund the Basic Health Care Provision Fund.124Uzochukwu B Onwujekwe O Mbachu C Implementing the basic health care provision fund in Nigeria: a framework for accountability and good governance.https: //resyst.lshtm.ac.uk/resources/implementing-the-basic-health-care-provision-fund-in-nigeria-a-framework-forDate: 2015Date accessed: September 1, 2021Google Scholar Such rules and statutory appropriations have the advantage of protecting part of the health budget from political processes. ( 3) Conditional grants: in both centralised and decentralised systems, the central government can influence resource allocation towards policy priorities through conditional grants that impose restrictions on the use of funds. Conditional grants can, additionally, be used to create incentives for specific spending ( eg, matching rules for National Health Mission grants in India; panel 9), impose governance requirements ( eg, audits or reporting requirements), or be supplemented with performance targets ( eg, Plan Nacer and Sumar in Argentina).126Gertler PJ Giovagnoli PI Martinez S Rewarding provider performance to enable a healthy start to life: evidence from Argentina's Plan Nacer. World Bank Policy Research Working Paper. The World Bank, Washington DC, WA2014Google Scholar These can be used to influence devolved or other local units to invest in certain programmes, leveraging centralised funds to expand overall PHC resources.Panel 9Conditional grants influence resource allocation in IndiaIn India's system of government, health is the responsibility of the subnational state governments. The Commission's case study on India examined mechanisms used by the central government to encourage states to invest in primary health care ( PHC).125Prinja S Muraleedharan VR How effective has the central government been in nudging the states for financing PHC? An analysis of fiscal federal relations in India. London: Lancet Global Health Commission on financing people-centred PHC.https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google ScholarThe National Health Mission, which was previously known as the National Rural Health Mission, is the main central programme for strengthening PHC. Under the National Health Mission, the federal government created a number of mechanisms to encourage states to fund PHC, including: •A matching rule for distribution of central level grants, which initially required states to contribute 15% of the total funds; the required contribution increased to 40% in 2016–17.•A planning process which included allowing the central government to conduct detailed reviews of PHC plans and budgets.•A system of performance assessment and accountability that made the release of a portion of the approved resources contingent on achieving a given level of performance. The performance-based component increased from 10% to 20% of the total National Health Mission funding and conditions were revised in 2018 though not yet implemented due to COVID-19 disruption.Over the period 2008 to 2019, state spending on PHC spending did increase. However, while the central government influenced the pattern of PHC spending, state-level respondents did not feel that these policy levers necessarily increased effective use of funds.
In India's system of government, health is the responsibility of the subnational state governments. The Commission's case study on India examined mechanisms used by the central government to encourage states to invest in primary health care ( PHC).125Prinja S Muraleedharan VR How effective has the central government been in nudging the states for financing PHC? An analysis of fiscal federal relations in India. London: Lancet Global Health Commission on financing people-centred PHC.https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar
The National Health Mission, which was previously known as the National Rural Health Mission, is the main central programme for strengthening PHC. Under the National Health Mission, the federal government created a number of mechanisms to encourage states to fund PHC, including: •A matching rule for distribution of central level grants, which initially required states to contribute 15% of the total funds; the required contribution increased to 40% in 2016–17.•A planning process which included allowing the central government to conduct detailed reviews of PHC plans and budgets.•A system of performance assessment and accountability that made the release of a portion of the approved resources contingent on achieving a given level of performance. The performance-based component increased from 10% to 20% of the total National Health Mission funding and conditions were revised in 2018 though not yet implemented due to COVID-19 disruption.
Over the period 2008 to 2019, state spending on PHC spending did increase. However, while the central government influenced the pattern of PHC spending, state-level respondents did not feel that these policy levers necessarily increased effective use of funds.
Budget execution processes in LMICs are often highly bureaucratic and focus on financial accountability rather than achieving outcomes. This focus on financial control might be due to concerns about corruption. The many stages of fund disbursement, as well as frequent delays in approval and release of funds, tend to reduce the amount and timeliness of funding that actually reaches PHC facilities and providers. The more remote the health facility, the fewer resources eventually arrive. This is not just an allocation problem; significant leakage and delay can occur during the many steps involved when disbursing funds from the central ministry of finance to a regional authority, then to local levels of government, and at last to facilities.127Gauthier B. PETS as a tool to improve accountability and transparency in public services. ODI 2020 Public Finance Conference; London; Feb 26, 2020.Google Scholar, 128Primary Health Care Performance InitiativeImprovement strategies model: funds.https: //improvingphcPHC.org/sites/default/files/Funds% 20last% 20updated% 2012.20.2019.pdfDate: 2019Date accessed: July 3, 2021Google Scholar, 129Goryakin Y Revill P Mirelman A Sweeney R Ochalek J Suhrcke M Public financial management and health service delivery, a literature review. Overseas Development Institute, London2017Google Scholar A particular challenge for PHC is that discretionary item allocations suffer the most from leakage and other execution problems; this leads to few resources being made available for the general operating costs of PHC facilities.116Cashin C Bloom D Sparkes S Barroy H Kutzin J O'Dougherty S Aligning public financial management and health financing: sustaining progress toward universal health coverage. WHO, Geneva2017Google Scholar Low levels of provider autonomy ( section 2) creates further rigidities in how resources are deployed. Various policy tools are available that can help to avoid or ameliorate these difficulties.
( 1) Resource allocation formulae: These are used to allocate resources ( among geographical units and levels of care) are policy levers that can promote equity in allocation. In its simplest form, a resource allocation formula allocates an equal per-capita amount across the recipient units. These formulae can be refined by adding adjustments, such as for differing health needs or local cost differences.130NHS EnglandFair shares: a guide to NHS allocations. NHS England and NHS Improvement, London2020Google Scholar For instance, health budgets in the English National Health Service are allocated among geographical units using a needs-adjusted formula. This approach inspired many countries to develop similar arrangements. Resource allocation formulae can also be used as part of budget rules and conditional grants.Resource allocation formulae have been effective in directing and protecting resources for PHC in both Chile and Brazil. In Chile, a per-capita amount for PHC is allocated to municipalities to operate PHC facilities ( panel 10).55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar In Brazil, the budget for the Family Health System is allocated to municipalities using a formula ( panel 11).107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google ScholarPanel 10Capitation-based resource allocation in ChileThe Commission's Chile case study examined the development, design, implementation, and effect of the capitation-based system for allocating resources to primary health care ( PHC) in Chile.55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google ScholarAfter its return to democracy in the 1990s, Chile replaced a system based on fee-for-service for PHC with one based on a per-capita-based allocation using a resource-allocation formula. The payments transferred to local governments are calculated according to the size of their population, adjusted to take account of the age, poverty, and rurality of a population. The local authority then allocates resources to PHC providers to cover the costs of salaries and services in accordance with the government's Family Health Plan. By 2019 this per capita allocation represented nearly 65% of the overall financing transfers for PHC. The payment system both serves to allocate resources to geographical units and is a means to pay providers. This capitation-based allocation has improved equity through the provision of more resources to poorer municipalities.One notable limitation of the system, however, is the low degree of financial integration between PHC and higher levels of care. Because diagnosis-related groups are used to pay for hospital services, clinical coordination and integration of care are more difficult. The risk adjustment mechanism is also considered to be quite crude, limiting possibilities for redistribution.Panel 11Brazil uses a population-based mechanism to allocate resources to the frontlineThe Commission's Brazil case study set out to understand the health financing arrangements that shaped the Family Health System.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar The Family Health System scaled up the provision of PHC through multidisciplinary teams who provided community-based services in a geographical area, shifting the way health-care services are delivered in Brazil.Financing of the Family Health System was through a direct transfer from the federal level to municipalities, known as the Piso da Atencao Basica ( meaning Floor for Basic Care). The transfer was calculated as a fixed per-capita amount based on municipal population and a variable component linked to federal priorities, including scale-up of the Family Health System model. From 2011, adjustments to the formula were introduced to allow more funds to be allocated to more deprived municipalities.Through this mechanism, regular and predictable resources were provided monthly to all municipalities for delivering primary health care ( PHC). Adjustments to the Piso da Atencao Basica arrangements were made over time to encourage municipalities to adopt the Family Health System model, expand the scope of PHC services provided, and to address health inequalities. This approach to financing PHC had clear impacts on reducing inequality in funding; although this effect was mitigated to a degree by the requirement to have a substantial municipal contribution to PHC funding.Supported by these financing arrangements, the number of Family Health System teams grew from 2054 to 43 286 between 1998 and 2020, covering 133·7 million people ( 63·3% of the population). A number of studies point to the effectiveness of the family health services in improving access to health care, reducing health inequalities and improving health outcomes.131Love-Koh J Mirelman A Suhrcke M Equity and economic evaluation of system-level health interventions: a case study of Brazil's Family Health Program.Health Policy Plan. 2021; 36: 229-238Google Scholar, 132Hone T Saraceni V Medina Coeli C et al.Primary healthcare expansion and mortality in Brazil's urban poor: a cohort analysis of 1.2 million adults.PLoS Med. 2020; 17e1003357Google ScholarHowever, with substantial disparities across municipalities in financial, administrative and technical capacities, inequalities across the country have persisted, and the availability of qualified health professionals in poorer and rural areas has constrained expansion of family health services. Recent developments, including fiscal austerity from 2016 onwards, political pressures to concentrate resources in specialised and hospital care, and the merger of financing blocks for PHC with secondary and tertiary hospitals threaten the achievements in financing an innovative PHC model over the past 20 years.A systematic review of the use of resource allocation formulae found that they enhanced equitable allocation of resources across provinces or smaller administrative units in Chile, Colombia, Zambia, and Zimbabwe.133Anselmi L Lagarde M Hanson K Equity in the allocation of public sector financial resources in low-and middle-income countries: a systematic literature review.Health Pol Plan. 2015; 30: 528-545Google Scholar The appropriate mix of local and central financing matters for equity, as greater dependence on local resources undermines equity. Various other forces can also constrain the equity achieved through the use of resource allocation formulae, including: failing to account for local differences in costs; failing to account for the absorptive capacity of each geographic area; and overlooking the up-front investments required to expand service provision. Scarcity of consistent and robust data to inform the components of resource allocation formulae ( eg, health status levels) at a given point in time can hinder the application and implementation of resource allocation formulae in LMIC.134WHOUnited Nations Children's Fund. Lesotho: Public health sector expenditure review. The World Bank, Washington, DC, WA2017Google Scholar, 135Piatti-Fünfkirchen M Ally M Tanzania: health sector public expenditure review. The World Bank, Washington DC, USA2020Google Scholar, 136Chansa C Workie NW Piatti M Matsebula T Yoo KJ Zambia: health sector public expenditure review. The World Bank, Washington, DC, USA2018Google ScholarFurthermore, simply applying resource allocation formulae does not ensure equitable distribution of resources. Okorafor and Thomas137Okorafor OA Thomas S Protecting resources for PHC under fiscal federalism: options for resource allocation.Health Policy Plan. 2007; 22: 415-426Google Scholar found that resource allocation formulae for PHC in South Africa were inequitable due to weak managerial capacity at lower levels of government, poor accounting for PHC expenditure, and lack of protection for PHC funds with regard to other service areas. ( 2) Direct facility funding: where public finance management systems fail to effectively channel money to PHC platforms and providers, whether due to leakages or other reasons, a second policy tool is to give money directly to the PHC level. Under direct facility funding, a health-care facility receives some core funding from the central level directly into its own bank account, usually to enable the purchasing of medicines and other supplies, or to pay for operating costs such as utilities. When coupled with autonomy to spend according to local priorities and sound facility financial management, direct facility funding can improve efficiency and quality of care.138O'Dougherty S Kutzin J Barroy H Piatti-Fünfkirchen M Margini F Direct facility financing: concept and role for UHC. 5th meeting of the Montreux collaborative on fiscal space, public financial management and health financing. WHO, Montreux2021Google Scholar Direct facility funding can also serve as a means to integrate multiple sources of financing at the facility level. For example, in Tanzania, the same formula is used to allocate resources from on-budget donor funds and the government budget ( excluding salaries and medical supplies).This approach was used in Kenya in the late 2000s,139Opwora A Kabare M Molyneux S Goodman C Direct facility funding as a response to user fee reduction: implementation and perceived impact among Kenyan health centres and dispensaries.Health Policy Plan. 2010; 25: 406-418Google Scholar Nigeria,140Nigeria Federal Ministry of HealthNigeria state health investment project ( NSHIP): project implementation manual.in: National Primary Health Care Development Agency Nigeria: Adamawa State Primary Health CarePHC Development Agency; 2012. Adamawa State Primary Health Care Development Agency, Nigeria2012: p3-11Google Scholar Tanzania,141Kapologwe NA Kalolo A Kibusi SM et al.Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol.Health Res Policy Syst. 2019; 17: 11Google Scholar Burkina Faso,138O'Dougherty S Kutzin J Barroy H Piatti-Fünfkirchen M Margini F Direct facility financing: concept and role for UHC. 5th meeting of the Montreux collaborative on fiscal space, public financial management and health financing. WHO, Montreux2021Google Scholar and Uganda.142Chee G Picillo B Strengths, challenges, and opportunities for RMNCH financing in Uganda. United States Agency for International Development, 2019https: //www.mcsprogram.org/resource/strengths-challenges-and-opportunities-for-rmnch-financing-in-uganda/Date accessed: December 1, 2021Google Scholar Direct facility funding can ensure that funds reach the periphery; it can have the added benefit of making PHC providers more visible in the public finance management system, raising the profile of spending on PHC. More evidence is required, however, about the effectiveness of direct facility funding in actually channelling funds to facilities, and by association facilitating the removal of user fees.138O'Dougherty S Kutzin J Barroy H Piatti-Fünfkirchen M Margini F Direct facility financing: concept and role for UHC. 5th meeting of the Montreux collaborative on fiscal space, public financial management and health financing. WHO, Montreux2021Google Scholar, 143Witter S Bertone M Diaconu K Review of Global Fund experience with facility-level financing. 5th Meeting of the Montreux Collaborative on Fiscal Space, Public Financial Management and Health Financing. WHO, Montreaux2021Google Scholar ( 3) Strategic purchasing: This incorporates specification of the benefit package, selection of eligible providers, and choice of provider payment methods. Done well, strategic purchasing promotes effectiveness, efficiency, and equity in a health system. However, a poorly ( or too narrowly) specified benefit package can cause patients, and therefore resources, to drift up the health-care system towards the hospital level. A benefit package that is too narrow, for example, might exclude routine management of chronic conditions. This can drive patients to seek care at levels of the system that are higher than necessary and expose them to risks of substantial out-of-pocket spending on medicines. However, various policy levers are available to address purchasing problems.
The Commission's Chile case study examined the development, design, implementation, and effect of the capitation-based system for allocating resources to primary health care ( PHC) in Chile.55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar
After its return to democracy in the 1990s, Chile replaced a system based on fee-for-service for PHC with one based on a per-capita-based allocation using a resource-allocation formula. The payments transferred to local governments are calculated according to the size of their population, adjusted to take account of the age, poverty, and rurality of a population. The local authority then allocates resources to PHC providers to cover the costs of salaries and services in accordance with the government's Family Health Plan. By 2019 this per capita allocation represented nearly 65% of the overall financing transfers for PHC. The payment system both serves to allocate resources to geographical units and is a means to pay providers. This capitation-based allocation has improved equity through the provision of more resources to poorer municipalities.
One notable limitation of the system, however, is the low degree of financial integration between PHC and higher levels of care. Because diagnosis-related groups are used to pay for hospital services, clinical coordination and integration of care are more difficult. The risk adjustment mechanism is also considered to be quite crude, limiting possibilities for redistribution.
The Commission's Brazil case study set out to understand the health financing arrangements that shaped the Family Health System.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar The Family Health System scaled up the provision of PHC through multidisciplinary teams who provided community-based services in a geographical area, shifting the way health-care services are delivered in Brazil.
Financing of the Family Health System was through a direct transfer from the federal level to municipalities, known as the Piso da Atencao Basica ( meaning Floor for Basic Care). The transfer was calculated as a fixed per-capita amount based on municipal population and a variable component linked to federal priorities, including scale-up of the Family Health System model. From 2011, adjustments to the formula were introduced to allow more funds to be allocated to more deprived municipalities.
Through this mechanism, regular and predictable resources were provided monthly to all municipalities for delivering primary health care ( PHC). Adjustments to the Piso da Atencao Basica arrangements were made over time to encourage municipalities to adopt the Family Health System model, expand the scope of PHC services provided, and to address health inequalities. This approach to financing PHC had clear impacts on reducing inequality in funding; although this effect was mitigated to a degree by the requirement to have a substantial municipal contribution to PHC funding.
Supported by these financing arrangements, the number of Family Health System teams grew from 2054 to 43 286 between 1998 and 2020, covering 133·7 million people ( 63·3% of the population). A number of studies point to the effectiveness of the family health services in improving access to health care, reducing health inequalities and improving health outcomes.131Love-Koh J Mirelman A Suhrcke M Equity and economic evaluation of system-level health interventions: a case study of Brazil's Family Health Program.Health Policy Plan. 2021; 36: 229-238Google Scholar, 132Hone T Saraceni V Medina Coeli C et al.Primary healthcare expansion and mortality in Brazil's urban poor: a cohort analysis of 1.2 million adults.PLoS Med. 2020; 17e1003357Google Scholar
However, with substantial disparities across municipalities in financial, administrative and technical capacities, inequalities across the country have persisted, and the availability of qualified health professionals in poorer and rural areas has constrained expansion of family health services. Recent developments, including fiscal austerity from 2016 onwards, political pressures to concentrate resources in specialised and hospital care, and the merger of financing blocks for PHC with secondary and tertiary hospitals threaten the achievements in financing an innovative PHC model over the past 20 years.
First is benefit specification. Having an explicitly defined and appropriate benefit package ( that was developed using realistic costing) is a way to secure and protect allocations to PHC. In Thailand, for example, capitation payments for PHC are based on a defined benefit package. Its Health Interventions and Technology Assessment Programme is a world leader in health technology assessment. Benefit specification can also require co-payments when patients bypass PHC, which helps to direct patients to the appropriate level of care.
Second is provider payment mechanisms, which determine how money is paid from pooled resources to service providers. As such, the provider payment system has a substantial influence on how resources are ultimately allocated across providers. As is elaborated in section 5, adopting a payment mechanism that directs money to PHC, such as capitation, makes PHC expenditure more visible, more equitable, and helps to protect allocations. Poor design of provider payment systems can also incentivise bypassing PHC, such as when providers are rewarded for referring patients to higher levels of the health system. Resources can also be diverted away from PHC when mechanisms for paying providers have money following patients ( for example, with fee-for-service payments) or are reinforced by an absence of gatekeeping or open-ended budgets at higher levels of the health system.
The effectiveness of a provider payment system as an allocation tool depends on the existence of complementary policies and properly aligned incentives. These include the coherence of provider payment systems across levels of care and payers, without which systems can decrease access, generate waiting lists, and overall decrease efficiency in the use of funding to provide care. It also can include health system organisation features such as gatekeeping and user incentives. Payment systems that constrain the budget at higher levels of the system ( sometimes called closed-ended payments) can help to protect resources for PHC; this approach is used in Thailand. PHC subpools can also do this function; for example, in Taiwan an umbrella budget for the national health insurance has five subpools, including one dedicated to PHC provided at independent ambulatory care clinics.144Cheng T-M Reflections on the 20th anniversary of Taiwan's single-payer national health insurance system.Health Affairs. 2015; 34: 502-510Google Scholar
Third is contracting and monitoring. Contracts between purchasers and providers can be designed to include provisions that help channel funds to PHC and constrain resources from being paid to hospitals. For instance, in Estonia, the national health insurance fund guarantees a minimum amount of revenue ( equivalent to the per-capita amount for 1200 individuals) for a defined list of PHC providers working in non-urban areas. This channels funds to PHC providers in sparsely populated areas and ensures that they can cover their fixed costs. More detail on Estonia's approach to PHC is provided in sections 5 and 6. Some contracts include volume caps on hospital payments, whereas others specify a facility level for payment for specific services. For example, in both China and Indonesia, purchasers will not pay for a service delivered at a level higher than appropriate. Contracts can also cover referral rules to limit unnecessary referrals to higher levels.
At times of crisis such as the COVID-19 pandemic, keeping money flowing through the system to frontline providers requires flexibility and adaptation of budget execution processes. Such flexibility also carries some risk. Keeping the focus on PHC is essential ( appendix p 4).
In many health systems, inappropriate incentives for both patients and providers have been created that encourage the bypassing of PHC, resulting in pulling resources away from frontline providers. The incentives to bypass PHC are reinforced by the vicious cycle cited in section 1: weak political support for PHC leads to chronic underfunding, which affects the capacity of PHC providers to offer quality services; this, in turn, causes users to mistrust PHC and they bypass this level of care, turning instead to hospitals and specialists.
These incentives might not have been created with the intention of undermining PHC. However, without strategic and coherent organisational linkages among levels of care, resources can drift up the system. For example, when user fees are set such that the cost of PHC is similar to the cost of higher levels of care, patients may feel encouraged to bypass PHC. In places that lack easily accessible and trusted PHC to serve as a first point of contact, patients are also likely to seek care directly ( if often unnecessarily) from specialists. Some innovative approaches intended to reinforce PHC by providing greater technical support to lower levels of care, such as the Health Care Alliances introduced in China, actually had the unintended effect of driving resources back to higher levels of the system.145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Various policy levers are available that, by improving the organisation of services, help to drive users and resources back to PHC: ( 1) Organisational definition of PHC: a clear operational definition of PHC helps to steer resources towards it by defining what functions must be supported and by providing a category for tracking PHC expenditure. In Indonesia, for example, the national health insurance programme defines a clear set of PHC facilities ( public and private) from which the PHC benefit package can be delivered. ( 2) Norms, standards and guidelines: establishing clear norms standards and guidelines for PHC ( including population coverage levels) can be a useful way to support allocation of resources to PHC. These declarations of how PHC is supposed to be delivered lend themselves to measuring resource requirements and tracking progress. The combination of a clear operational definition of PHC and service delivery norms makes it easier to cost PHC and to determine what level of funding is needed to deliver it. In Ethiopia, the expansion of PHC followed a stated objective: each PHC Unit ( made up of one health centre and five health posts) would serve 25 000 people, including community-level services provided by two health extension workers per kebele ( 5000 people) in each health post. This clear standard enabled the government to estimate its resource needs and then translate the estimates into a costed plan that involved the construction of 15 000 health posts and 3200 health centres. The plan proved to be a powerful instrument when negotiating with both donors and government finance officials. The investments required for human resources to staff the new units were also determined based on the plan. Challenges remain, of course; these facilities are still developing the capacity to deliver the full set of PHC services, and there remain shortages of certain cadres of staff, particularly doctors and midwives.146Alebachew A Hatt L Kukla M Monitoring and evaluating progress towards universal health coverage in Ethiopia.PLoS Med. 2014; 11e1001696Google Scholar ( 3) Service delivery model: changing the service delivery model such that it effectively pulls resources to the PHC level. With appropriate financing mechanisms, service delivery arrangements that strengthen PHC can stimulate demand and help to pull resources to PHC. Different approaches have been implemented. For example, on the one hand, Brazil's Family Health System introduced multidisciplinary teams that operate at municipal level and are financed through the per-capita allocations paid directly to municipalities.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar Ethiopia, on the other hand, has developed a new model of PHC service delivery with the introduction of a new cadre. Health extension workers receive a year of preservice training and are paid a government salary to work from health posts at the village ( kebele) level.118Woldie M Resource mobilisation and allocation for PHCPHC: lessons from the Ethiopian health system. London: Lancet Global Health commission on financing people-centred PHC.https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar ( 4) Referral systems and gatekeeping: protecting resource allocations to PHC includes directing patients and resources to the appropriate levels of care. Gatekeeping policies, in which patients must be referred from PHC providers to access specialist care, and measures such as empanelment and registration which link patients to providers, can help to influence care seeking and direct patients to use the lowest level of care at which their condition can be effectively managed. However, effective gatekeeping requires having functional referral systems in place so that patients can be rapidly sent to the appropriate level of care. Many health systems, especially in LMICs, do not have those systems in place. Where strict gatekeeping is not feasible, financial disincentives or incentives—such as higher co-payments for higher levels of care—can deter patients from bypassing PHC. In France, for example, a preferred doctor scheme was introduced in 2005, aiming to reduce the number of visits to outpatient specialists. Those who continued to self-refer to a specialist incurred a higher co-payment than those who were referred via their preferred doctor, which led to fewer specialist consultations.147Dumontet M Buchmueller T Dourgnon P Jusot F Wittwer J Gatekeeping and the utilization of physician services in France: evidence on the Médecin traitant reform.Health Policy. 2017; 121: 675-682Google Scholar
These and other policy levers will be more or less appropriate and effective depending on the specific context of each health system. Further, many problems exist within these approaches that have yet to be successfully addressed. Therefore, identifying new ways of improving the allocation of resources to support high-quality PHC service delivery remains a key challenge for policy makers.
Essential public health functions and global common goods148Soucat A Financing common goods for health: fundamental for health, the foundation for UHC.Health Syst Reform. 2019; 5: 2632763-2632767Google Scholar are part of PHC. They include activities whose importance has become particularly evident during the COVID-19 pandemic, such as public communication, disease surveillance, testing, contact tracing, support for affected individuals or communities, basic laboratory services, safe water supplies, sanitation, and hygiene. Mitigation of the impacts of environmental pollution and climate change on population health might also fall under the rubric of essential public health functions, with implications for health financing that is people centred. Financing population-focused interventions require different arrangements, sectoral engagement, systems, and capacity from individual primary care; however, many of the same principles and policy levers apply. Any national strategy for delivering essential public health functions should: create coherent priorities, clarify who is responsible for what, and align budgeting processes to ensure that these are adequately funded.149Sparkes SP Kutzin J Earle AJ Financing common goods for health: a country agenda.Health Syst Reform. 2019; 5: 322-333Google Scholar, 150Rechel B Maresso A Sagan A et al.Organization and financing of public health services in Europe: country reports. WHO Regional office for Europe, Copenhagen2018Google Scholar Financing for public health services frequently receives inadequate attention in government budgets; however, this financing is crucial for prevention and addressing the determinants of disease.
Essential public health functions can also suffer from fragmentation and ineffective organisational arrangements, with multiple payers involved and different government and non-government organisations responsible for delivery. Financing and formalising the regulation of private sector activity with population health impacts might be particularly important in considering public finance allocations to PHC at national and subnational levels. For example, subnational jurisdictions that benefit financially by taxing or partnering with polluting or extractive industries whose waste harms population health could reasonably be expected to fund essential public health functions or the additional services needed to mitigate these impacts.
In this Commission, we argue that a systems approach to financing is especially important for essential public health functions. This approach starts with clarifying who has responsibility for budgeting, planning, and ensuring that the essential public health functions are adequately resourced and delivered. As in other aspects of PHC, alignment of donor funding with national budgets and plans is also crucial. Decentralisation might result in insufficient resources for essential public health functions. Uniform national ( and even regional) standards are essential; this requires system-wide coordination and standards across subnational units. However, the relative invisibility of these services and their benefits, and the required coordination of multiple sectors, might make them unappealing to local governments.
The policy levers detailed above can also be applied to securing financing for essential public health functions. For example, programme budgets can help to connect resource allocations to priorities and targets, whereas fiscal rules such as matching grants or resource allocation formulae can protect resources for essential public health functions. In some cases, however, it will be necessary to create new institutions to finance and deliver essential public health functions. For example, the Thai Health Promotion Foundation, which receives a share of the proceeds from national excise taxes, has responsibility for providing population-based health promotion activities. Private sector activities with an impact on population health should contribute to essential public health functions as appropriate.
One challenge in financing PHC is the institutional design of many ministries of health, which are structured around health programmes ( eg, department of maternal and child health, department of communicable diseases, and department of non-communicable diseases) rather than functions, levels, or service delivery platforms. Although it might not be operationally necessary or feasible to have a specific department for PHC, it is important that the responsibility for setting priorities for spending on PHC, and monitoring these, sits within an identified department or unit.
A key supporting function for resource allocation to PHC is the public financial management system through which budgets are developed and executed. Such systems are usually not unique to the health sector, and their strengthening may benefit from cross-sectoral initiatives to improve broader social sector financing and budget processes. Specific adaptation for the health sector might reduce paralysing bureaucracy. Strengthening public financial management, as well as PHC provider platforms ' capacity to deal with finances, requires technical skill and the ability to collect, analyse, and interpret data on the population and its health needs to cost PHC benefits and required services. Another supporting function is the efficient deployment and management of the health workforce, including cadres at community level.
When based on a clear operational definition of PHC, these budget formulation, budget execution, and service organisation policy tools can be deployed in concert to help ensure that sufficient resources are allocated to meet the needs of PHC that is people centred, and to protect the resources so that they reach the PHC delivery platforms. In Thailand, for instance, the budget for PHC is safeguarded through the combined effects of a defined PHC benefit package, ring-fencing of the PHC budget ( and constraints on the budget for higher levels of the system), and capitation payment for PHC.
How can countries begin to move in this direction? We suggest that it begins at the budget formulation stage. Working towards developing a programme budget would be helpful to PHC, using other policy levers as necessary. At budget execution stage, a well-developed resource allocation formula can be a useful starting point for improving allocation of financing to PHC. Even a simple per-capita formula, with risk equalisation and performance and quality incentives added as the system develops, can begin to foster equity in universal coverage of a basic package of primary care services. For a formula to be effective, however, other reforms that link budget allocations to PHC are also needed.
For any of these policy levers to be feasible, various health system and financial capacities need to be strengthened as well, such as budget management capacity at the Ministry of Health, high-quality data on health status and needs, and effective accounting practices. Figure 10 sets out these capacities.Figure 10Health and public finance management system capacities needed to exercise public finance management policy leversShow full captionPFM=public finance management. * Direct facility funding also requires individual facility bank accounts.View Large Image Figure ViewerDownload Hi-res image Download ( PPT)
PFM=public finance management. * Direct facility funding also requires individual facility bank accounts.
Decentralised systems are closer to populations than centralised ones and have the potential to provide more flexible and responsive PHC services. However, they are at higher risk of local management problems and inequities. It can also be more difficult to influence resource allocation in decentralised systems.
Regardless of the type of system in any country, strong monitoring, performance management, and enforcement of appropriate budget and public finance management systems to ensure that resources reach PHC are as important as the initial process of resource allocation.
The Commission recognises that it is often difficult to make major or rapid shifts in allocation of resources in existing systems. In most cases, the discussion must be about incrementally influencing spending. However, as the COVID-19 pandemic has shown, sometimes major disruptions can create space for major reforms ( and across multiple sectors) if appropriate policies have been identified in advance. Ultimately, these are complex processes that pose significant implementation challenges. Further, they rely on having data on variables such as costs and activities, together with numerous other supporting functions and systems. Ultimately, all of these systems are driven by human behaviour. Thus the following section addresses a key feature of every complex system for financing PHC: how it organizes the incentives for people to deliver and access high quality people-centred PHC.
Provider payment and incentives are another tool to ensure resources reach frontline providers and are used most efficiently. Countries can do more to create incentives that direct the behaviour of organisations that provide PHC and users towards people-centred PHC. In this section, we propose our vision of the PHC payment system based on a concrete set of principles. We describe the pathway countries can follow to make progress towards this vision and lay out the basic functions that need to be strengthened along the way. We also consider what motivates individual health workers, including the need to foster a culture of professionalism. Finally, we examine the role of provider payment policy in reducing financial barriers for those in need of PHC. Key messages from Section 5 are presented in panel 12.Panel 12Getting incentives right for primary health care ( PHC) –key messages•Incentive policies for providers and users are inextricably intertwined: PHC provider payment policies are integral to the elimination of user fees and informal payments for PHC services.•Incentives alone can not solve all PHC financing problems, but they should at least not work against PHC service delivery objectives.•The Commission's vision of how PHC provider organisations should be paid is a context-specific blended payment model with capitation at its centre because that is most aligned with the principles and objectives of PHC.•The blended payment model purposively combines capitation with elements of other payment methods ( such as fee-for-service or performance-based bonuses for selected high priority services, and budgets to cover unavoidable fixed costs) to maximise beneficial incentives and offsets perverse incentives of each payment method, while ensuring other service delivery objectives, such as access, are met.•Countries should only embark on provider payment reform when they are ready. The transformation of the PHC provider payment system is a complex process with distinct political economy challenges. The aim is to make incremental progress that involves continually strengthening supporting systems as the payment model evolves.
•Incentive policies for providers and users are inextricably intertwined: PHC provider payment policies are integral to the elimination of user fees and informal payments for PHC services.•Incentives alone can not solve all PHC financing problems, but they should at least not work against PHC service delivery objectives.•The Commission's vision of how PHC provider organisations should be paid is a context-specific blended payment model with capitation at its centre because that is most aligned with the principles and objectives of PHC.•The blended payment model purposively combines capitation with elements of other payment methods ( such as fee-for-service or performance-based bonuses for selected high priority services, and budgets to cover unavoidable fixed costs) to maximise beneficial incentives and offsets perverse incentives of each payment method, while ensuring other service delivery objectives, such as access, are met.•Countries should only embark on provider payment reform when they are ready. The transformation of the PHC provider payment system is a complex process with distinct political economy challenges. The aim is to make incremental progress that involves continually strengthening supporting systems as the payment model evolves.
An incentive is an economic signal that directs individual health workers, health provider organisations, and patients towards self-interested behaviour. We know that incentives influence the performance of PHC providers and the behaviour of users.151Flodgren G Eccles MP Shepperd S Scott A Parmelli E Beyer FR An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes.Cochrane Database Syst Rev. 2011; 7CD009255Google Scholar However, getting incentives right is not a panacea. As noted in section 4, the key problem in many LMICs is that insufficient resources actually reach PHC providers. No amount of tweaking incentives will help when newly qualified professionals often look to establish lucrative specialist practices and facilities are poorly equipped, making it difficult to staff primary care clinics. Dual practice, widely observed in LMICs, is a symptom of precisely this problem.152Hipgrave DB Hort K Dual practice by doctors working in South and East Asia: a review of its origins, scope and impact, and the options for regulation.Health Policy Plan. 2014; 29: 703-716Google Scholar To deliver high-quality PHC, it is essential that doctors, nurses, and other cadres of staff are valued, with adequate remuneration and conditions of work to attract them into PHC as a long-term career choice.96World BankWalking the talk: reimagining PHC after COVID-19. World Bank, Washington, DC, WA2021Google Scholar, 153WHOGlobal strategy on human resources for health: workforce 2030. World Health Organization, Geneva2016Google Scholar
In many countries, the way health-care providers are paid often works against the objectives of PHC. In systems that pay providers a fee for a service, they typically set higher payment rates for specialty services, giving providers a financial incentive to prioritise curative, rather than preventive, care. In many LMICs, people lack trust in PHC and choose to seek care at higher levels, even if they have to pay more. Addressing these problems is especially difficult when funding and provider payment systems for PHC are fragmented. Case studies from LMICs have documented that the typical PHC provider receives funding from multiple payers using different payment systems for different population groups.154Barasa E Mathauer I Kabia E et al.How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them.Health Policy Plan. 2021; 36: 861-868Google Scholar In addition to creating administrative hurdles for PHC providers, when payments are poorly coordinated, the incentives generated might not align well ( or might even conflict) with the objectives of PHC. These incentives can instead drive providers to prioritise certain patient groups in ways that exacerbate inequities or health services that are of low value to patients but lucrative for providers. Some of these problems are evident in China, as described in panel 13.Panel 13China's experience with fragmented payment structures for primary health care ( PHC) The Commission's China case study focused on the fragmentation of PHC financing.145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar In China, PHC is mainly provided at village clinics and township health centres in rural areas and at community health centres and stations in urban areas. Financing for these institutions comes mainly from two sources: social health insurance and the essential public health fund. Social health insurance pays for a medical care package largely using fee-for-service payment, whereas the essential public health fund pays for a package of public health services using a population-based method ( capitation). These two sources of funding are managed by different government authorities at both the national and local levels: social health insurance is managed by the Department of Social Medical Security, whereas the essential public health fund is managed by the Department of Health.This fragmented payment system has been a barrier to integrated PHC for several reasons. First, a lack of coordination between the two funds ' administrative authorities has resulted in separate delivery of medical and public health services. Second, fragmented funding can make it difficult for different cadres of PHC providers to coordinate their services, even when they are working within the same institution. For payment purposes, PHC providers try to maintain clear boundaries between the medical and public health services they offer; this is difficult, particularly in the case of services for non-communicable diseases. For example, payment incentives might lead doctors to focus only on providing medical services, even if they should also be playing important roles in disease prevention and public health services. Third, separate information systems have been established for the medical and public health services, making it difficult to manage the health of individuals and communities holistically. Finally, the performance of various PHC providers is evaluated separately by social health insurance and the essential public health fund, impeding the health system's ability to determine whether it is achieving its objectives. The existing incentives are not aligned to encourage medical and public health providers to coordinate, or even share information, with each other, although they are serving the same community members. A number of counties in China have recently begun to experiment with changing this fragmented financing situation by pooling the two sources of funding for PHC to pay family doctor teams. The intention of this innovation is to encourage greater continuity and integration in PHC.
The Commission's China case study focused on the fragmentation of PHC financing.145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar In China, PHC is mainly provided at village clinics and township health centres in rural areas and at community health centres and stations in urban areas. Financing for these institutions comes mainly from two sources: social health insurance and the essential public health fund. Social health insurance pays for a medical care package largely using fee-for-service payment, whereas the essential public health fund pays for a package of public health services using a population-based method ( capitation). These two sources of funding are managed by different government authorities at both the national and local levels: social health insurance is managed by the Department of Social Medical Security, whereas the essential public health fund is managed by the Department of Health.
This fragmented payment system has been a barrier to integrated PHC for several reasons. First, a lack of coordination between the two funds ' administrative authorities has resulted in separate delivery of medical and public health services. Second, fragmented funding can make it difficult for different cadres of PHC providers to coordinate their services, even when they are working within the same institution. For payment purposes, PHC providers try to maintain clear boundaries between the medical and public health services they offer; this is difficult, particularly in the case of services for non-communicable diseases. For example, payment incentives might lead doctors to focus only on providing medical services, even if they should also be playing important roles in disease prevention and public health services. Third, separate information systems have been established for the medical and public health services, making it difficult to manage the health of individuals and communities holistically. Finally, the performance of various PHC providers is evaluated separately by social health insurance and the essential public health fund, impeding the health system's ability to determine whether it is achieving its objectives. The existing incentives are not aligned to encourage medical and public health providers to coordinate, or even share information, with each other, although they are serving the same community members. A number of counties in China have recently begun to experiment with changing this fragmented financing situation by pooling the two sources of funding for PHC to pay family doctor teams. The intention of this innovation is to encourage greater continuity and integration in PHC.
Chronic underfunding of PHC, fragmented revenue streams, and misaligned provider incentives all contribute to the fundamental problem mentioned in sections 2 and 3: that many users in LMICs pay out-of-pocket fees for PHC services, which act as a barrier ( disincentive) to accessing PHC, particularly for the poorest; for those who do choose to pay, user fees can lead to financial hardship.74James CD Hanson K McPake B et al.To retain or remove user fees? Reflections on the current debate in low- and middle-income countries.Appl Health Econ Health Policy. 2006; 5: 137-153Google Scholar, 75Gilson L McIntyre D Removing user fees for primary care in Africa: the need for careful action.BMJ. 2005; 331: 762-765Google Scholar
Each option for paying PHC providers generates certain incentives that have been described in the literature.155Cashin C Gubanova O Kadyrova N et al.Primary health carePHC per capita payment systems.in: Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, WA2009Google Scholar, 156Cashin C Ankhbayar B Phuong HT et al.Assessing health provider payment systems: a practical guide for countries working toward universal health coverage.https: //www.jointlearningnetwork.org/wp-content/uploads/2019/11/JLN ProviderPayment MainGuide InteractivePDF.pdfDate accessed: July 18, 2021Google Scholar, 157Robinson JC Theory and practice in the design of physician payment incentives.Milbank Q. 2001; 79: 149-177Google Scholar The key insight from the empirical evidence on the effectiveness of different payment methods is that no single payment method is perfect. Each payment method carries advantages and disadvantages.158Lagarde M, Powell-Jackson T, Blaauw D. Managing incentives for health providers and patients in the move towards universal coverage: technical report. Global Symposium on Health Systems Research; Nov 9, 2010. Montreaux, Switzerland; 2010. Montreaux, Switzerland: First Global Symposium on Health Systems Research, 2010: p15–35.Google Scholar, 159Tan SY Melendez-Torres GJ Do prospective payment systems ( PPSs) lead to desirable providers ' incentives and patients ' outcomes? A systematic review of evidence from developing countries.Health Policy Plan. 2018; 33: 137-153Google Scholar, 160Jia L Meng Q Scott A Yuan B Zhang L Payment methods for healthcare providers working in outpatient healthcare settings.Cochrane Database Syst Rev. 2021; 1CD011865Google Scholar, 161Roland M Olesen F Can pay for performance improve the quality of primary care?.BMJ. 2016; 354i4058Google Scholar Many countries have therefore moved towards a blended payment system, which combines elements of multiple payment methods, in part to maximise the beneficial incentives and minimise the perverse incentives of each option. We describe the main categories of payment method used for PHC.
•Tying payments to inputs, as with a line-item or global budget, is a passive form of purchasing. It provides a facility and its staff with a stable income, which is especially important in hard-to-serve areas, and contains costs. However, this provider payment method generates no strong incentives for providers to address the health needs of the population in the catchment area. Input-based budgets are often rigid, so providers can not easily move funds across budget lines to respond to local needs ( eg, they can not choose to cut utility costs to spend more on medicines).•Paying for services, typified by a fee-for-service system ( not to be confused with user fees) in which the provider receives a payment from the institutional payer for each service provided, prioritises meeting users ' demands. However, it carries many disadvantages, including an incentive to provide more care than is needed ( particularly services with higher fees) and rarely prioritises preventive care. Pay-for-performance is a common add-on to other payment methods, whose purpose is to incentivise high-quality care through bonuses for reaching service coverage or quality targets, but can in principle result in gaming and the neglect of aspects of care that are not being measured.162Roland M Dudley RA How financial and reputational incentives can be used to improve medical care.Health Serv Res. 2015; 50: 2090-2115Google Scholar, 163Rosenthal MB Dudley RA Pay-for-performance: will the latest payment trend improve care?.JAMA. 2007; 297: 740-744Google Scholar•Population-based payment, which in this Commission we refer to as capitation, gives providers a fixed per-person payment, determined and paid in advance, to deliver a defined set of services to each enrolled individual for a specified period of time. Under capitation, continuity of care, a key prerequisite for successful PHC, is built into the reimbursement mechanism. Providers have an incentive to attract more patients to their practices and contain costs. However, a provider's revenue might not be enough to cover the costs of serving the population if some groups have higher needs than anticipated by the payment formula or if payment rates are set too low. In this case, there might be an incentive to avoid enrolling higher-need individuals, refer patients unnecessarily to specialists for care that could be provided in primary care, and skimp on quality of care.
The payment system itself is not the only force creating incentives for providers. Broader purchasing arrangements, including contracting, monitoring of provider performance, and population enrolment, can also generate both financial and non-financial incentives. For example, conditions of contracting, such as accreditation status or data reporting requirements, might create incentives for providers to improve their quality standards and upgrade information systems. Contracting arrangements might also specify service delivery standards, often tied to national clinical guidelines; this creates additional financial incentives if those standards must be met for providers to be paid.
The Commission's vision for PHC provider payment is a context-specific blended payment model built on capitation. This structure embodies principles that the Commission argues should form the core of PHC. Payment systems should allow adequate resources to flow to the PHC level in ways that: are equitable; match resources to population health needs; create the right incentive environment to promote the full PHC spectrum of prevention, health promotion, and management and treatment; foster people-centeredness, continuity and quality of PHC; and are flexible enough to support changes in service delivery models and approaches.
Capitation is a prospective population payment system.164Health Care Payment Learning and Action NetworkAlternative payment model: APM Framework: refreshed 2017. Health care payment learning & action network.https: //hcp-lan.org/apm-refresh-white-paper/Date: 2017Date accessed: July 18, 2021Google Scholar Because it is not tied to specific inputs or the volume of services delivered, capitation payment gives providers flexibility to coordinate and optimally manage care for individuals and populations. It is the only payment method that is based on the principle of equity, as its starting point is an equal fixed payment per person, which can then be adjusted based on health needs or other factors. Capitation payment is the only method that pays PHC providers for managing population health and prioritises preservation of good health, rather than delivering individual services to address health problems. As a prepayment-based system, capitation also provides a predictable and stable revenue stream to PHC providers that can be used to flexibly deliver services in responsive ways.156Cashin C Ankhbayar B Phuong HT et al.Assessing health provider payment systems: a practical guide for countries working toward universal health coverage.https: //www.jointlearningnetwork.org/wp-content/uploads/2019/11/JLN ProviderPayment MainGuide InteractivePDF.pdfDate accessed: July 18, 2021Google Scholar, 165Langenbrunner J Cashin C O'Dougherty S Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, USA2009Google Scholar
As PHC service delivery models become more community-based, patient-driven, and technology-enabled, payment methods need to be flexible enough to adapt to more varied, complex, and dynamic service delivery. Payment should compensate providers for delivering all services specified in a PHC package, some of which might not appear in typical fee-for-service lists or are not delivered in facility-based settings ( such as essential public health functions, telemedicine, care management, or patient engagement). Capitation payment is flexible and can be redirected quickly in support of the service delivery model, as under this model providers have a large degree of financial and managerial autonomy.
If capitation has so many benefits, why does the Commission recommend a blended payment model? As noted above, capitation payment also has some clear drawbacks, such as encouraging underprovision, selection bias towards low-need patients, and unnecessary referrals to other levels of care.157Robinson JC Theory and practice in the design of physician payment incentives.Milbank Q. 2001; 79: 149-177Google Scholar Blended payment models bring the benefits of capitation as the starting point and then use elements of other payment mechanisms to deliberately offset capitation's disadvantages and support achieving other specific health system objectives.157Robinson JC Theory and practice in the design of physician payment incentives.Milbank Q. 2001; 79: 149-177Google Scholar, 166Cattel D Eijkenaar F Value-based provider payment initiatives combining global payments with explicit quality incentives: a systematic review.Med Care Res Rev. 2020; 77: 511-537Google Scholar
Blended payment models for PHC typically include a budget payment to cover unavoidable fixed costs, particularly in low-population or hard-to-serve areas; some fee-for-service carve-outs for health conditions or services that are high priority or at higher risk of being underprovided in capitation; and, in some cases, performance-based payment to incentivise reaching coverage targets for priority services and improving quality of care. Other complexities may be added to align with evolving and innovative service delivery models ( panel 14).Panel 14Paying for integrated careDifferences in health financing arrangements, including payment methods, are frequently cited as a major barrier to more integrated approaches of service delivery. Successful integration requires sustained investment in staff and support systems, funding for start-up costs, and flexibility to respond to needs that emerge during implementation.167Leutz WN Five laws for integrating medical and social services: Lessons from the United States and the United Kingdom.Milbank Q. 1999; 77: 77-110Google Scholar A review of the evidence ( mostly from high-income countries) found that a range of mechanisms have been used, often in combination, to achieve better service integration.54Nolte E Woldmann L Financing and reimbursement.in: Amelung V Stein V Goodwin N Balicer R Nolte E Suter E Handbook integrated care. Springer International Publishing, Switzerland2021: 341-364Google Scholar This includes the commitment of dedicated resources to support the development of innovative care models, such as through targeted payments to finance infrastructure for provider networks, or the use of start-up grants to promote care coordination and integration activities.168North J Achieving Person-Centred Health Systems. Evidence, strategies, and challenges. Cambridge University Press, Cambridge2020Google Scholar Countries are also increasingly experimenting with what has been referred to as value-based payments, which seek to link provider payment to a predefined set of evidence-based clinical process or outcome measures.166Cattel D Eijkenaar F Value-based provider payment initiatives combining global payments with explicit quality incentives: a systematic review.Med Care Res Rev. 2020; 77: 511-537Google Scholar Examples of value-based payment include bundled payments, shared savings, and global budgets.Bundled and global payments are disbursed as a single payment in form of a lump sum per period for a specified population ( global payment) or per episode or condition per patient ( bundled payment) to a collective of providers. By linking payment to clinical, process, and outcome measures, providers are incentivised to increase efforts to improve patient care and process efficiency. As the payment is transferred as a single lump sum, regardless of the number of services provided, value-based payments are expected to promote care coordination and integration across providers and so reduce wasteful duplication of services and unnecessary hospital use. The Netherlands and various states in the USA have introduced disease-based bundled payment schemes for mostly chronic conditions, such as type 2 diabetes or cardiovascular disease.169Conrad DA Vaughn M Grembowski D Marcus-Smith M Implementing value-based payment reform: a conceptual framework and case examples.Med Care Res Rev. 2016; 73: 437-457Google Scholar, 170de Bakker DH Struijs JN Baan CB et al.Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination.Health Aff. 2012; 31: 426-433Google Scholar These involve reimbursing providers for a package of services on a predefined patient pathway per patient and for periods of up to 1 year. Global payment models include shared savings programmes and comprehensive care payments. Shared savings programmes essentially mean that the payer and providers share the risk of rising expenditure, that is, providers that successfully lower their growth in health-care costs while continuing to meet quality standards will be able to keep the savings and reinvest them. Examples include the Medicare Shared Savings Program in the USA and the Healthy Kinzigtal integrated care programme in Germany.171Pimperl A Schulte T Mühlbacher A et al.Evaluating the impact of an accountable care organization on population health: the quasi-experimental design of the german gesundes kinzigtal.Popul Health Manag. 2017; 20: 239-248Google Scholar Global payment models involve fixed payments for the care of a patient during a specified time period. Several countries have additionally introduced pay-for-improvement, pay-for-coordination, or pay-for-performance schemes in primary care, incentivising chronic and coordinated care in particular, although the evidence of their benefits remains mixed.Finally, a number of countries have experimented with different financing mechanisms, such as shifting responsibility for funding of particular components of service delivery between funding agencies.172Maarse JAM Jeurissen PP The policy and politics of the 2015 long-term care reform in the Netherlands.Health Policy. 2016; 120: 241-245Google Scholar Others have introduced pooled funds to integrate health and social care or structurally integrated budgets, in which responsibilities for health and social care are combined within a single body under single management, such as within the Integrated Health and Social Care Board in Northern Ireland.The evidence of what works remains patchy. However, an important lesson is that “ integration costs before it pays ”.167Leutz WN Five laws for integrating medical and social services: Lessons from the United States and the United Kingdom.Milbank Q. 1999; 77: 77-110Google Scholar Indeed, evaluations of novel schemes often find an increase in cost, mainly because the new service delivery model uncovers unmet need.173Mason A Goddard M Weatherly H Chalkley M Integrating funds for health and social care: an evidence review.J Health Serv Res Policy. 2015; 20: 177-188Google Scholar The creation of new coordinating mechanisms will not compensate for lack of resources. The injection of one-off extra funding to pay for new services will not necessarily ensure long-term sustainability, particularly where new approaches fail to be incorporated into routine care.
Differences in health financing arrangements, including payment methods, are frequently cited as a major barrier to more integrated approaches of service delivery. Successful integration requires sustained investment in staff and support systems, funding for start-up costs, and flexibility to respond to needs that emerge during implementation.167Leutz WN Five laws for integrating medical and social services: Lessons from the United States and the United Kingdom.Milbank Q. 1999; 77: 77-110Google Scholar A review of the evidence ( mostly from high-income countries) found that a range of mechanisms have been used, often in combination, to achieve better service integration.54Nolte E Woldmann L Financing and reimbursement.in: Amelung V Stein V Goodwin N Balicer R Nolte E Suter E Handbook integrated care. Springer International Publishing, Switzerland2021: 341-364Google Scholar This includes the commitment of dedicated resources to support the development of innovative care models, such as through targeted payments to finance infrastructure for provider networks, or the use of start-up grants to promote care coordination and integration activities.168North J Achieving Person-Centred Health Systems. Evidence, strategies, and challenges. Cambridge University Press, Cambridge2020Google Scholar Countries are also increasingly experimenting with what has been referred to as value-based payments, which seek to link provider payment to a predefined set of evidence-based clinical process or outcome measures.166Cattel D Eijkenaar F Value-based provider payment initiatives combining global payments with explicit quality incentives: a systematic review.Med Care Res Rev. 2020; 77: 511-537Google Scholar Examples of value-based payment include bundled payments, shared savings, and global budgets.
Bundled and global payments are disbursed as a single payment in form of a lump sum per period for a specified population ( global payment) or per episode or condition per patient ( bundled payment) to a collective of providers. By linking payment to clinical, process, and outcome measures, providers are incentivised to increase efforts to improve patient care and process efficiency. As the payment is transferred as a single lump sum, regardless of the number of services provided, value-based payments are expected to promote care coordination and integration across providers and so reduce wasteful duplication of services and unnecessary hospital use. The Netherlands and various states in the USA have introduced disease-based bundled payment schemes for mostly chronic conditions, such as type 2 diabetes or cardiovascular disease.169Conrad DA Vaughn M Grembowski D Marcus-Smith M Implementing value-based payment reform: a conceptual framework and case examples.Med Care Res Rev. 2016; 73: 437-457Google Scholar, 170de Bakker DH Struijs JN Baan CB et al.Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination.Health Aff. 2012; 31: 426-433Google Scholar These involve reimbursing providers for a package of services on a predefined patient pathway per patient and for periods of up to 1 year. Global payment models include shared savings programmes and comprehensive care payments. Shared savings programmes essentially mean that the payer and providers share the risk of rising expenditure, that is, providers that successfully lower their growth in health-care costs while continuing to meet quality standards will be able to keep the savings and reinvest them. Examples include the Medicare Shared Savings Program in the USA and the Healthy Kinzigtal integrated care programme in Germany.171Pimperl A Schulte T Mühlbacher A et al.Evaluating the impact of an accountable care organization on population health: the quasi-experimental design of the german gesundes kinzigtal.Popul Health Manag. 2017; 20: 239-248Google Scholar Global payment models involve fixed payments for the care of a patient during a specified time period. Several countries have additionally introduced pay-for-improvement, pay-for-coordination, or pay-for-performance schemes in primary care, incentivising chronic and coordinated care in particular, although the evidence of their benefits remains mixed.
Finally, a number of countries have experimented with different financing mechanisms, such as shifting responsibility for funding of particular components of service delivery between funding agencies.172Maarse JAM Jeurissen PP The policy and politics of the 2015 long-term care reform in the Netherlands.Health Policy. 2016; 120: 241-245Google Scholar Others have introduced pooled funds to integrate health and social care or structurally integrated budgets, in which responsibilities for health and social care are combined within a single body under single management, such as within the Integrated Health and Social Care Board in Northern Ireland.
The evidence of what works remains patchy. However, an important lesson is that “ integration costs before it pays ”.167Leutz WN Five laws for integrating medical and social services: Lessons from the United States and the United Kingdom.Milbank Q. 1999; 77: 77-110Google Scholar Indeed, evaluations of novel schemes often find an increase in cost, mainly because the new service delivery model uncovers unmet need.173Mason A Goddard M Weatherly H Chalkley M Integrating funds for health and social care: an evidence review.J Health Serv Res Policy. 2015; 20: 177-188Google Scholar The creation of new coordinating mechanisms will not compensate for lack of resources. The injection of one-off extra funding to pay for new services will not necessarily ensure long-term sustainability, particularly where new approaches fail to be incorporated into routine care.
Pay-for-performance has received considerable attention from policy makers and researchers in the last two decades.174Diaconu K Falconer J Verbel A Fretheim A Witter S Paying for performance to improve the delivery of health interventions in low- and middle-income countries.Cochrane Database Syst Rev. 2021; 5CD007899Google Scholar, 175Mendelson A Kondo K Damberg C et al.The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review.Ann Intern Med. 2017; 166: 341-353Google Scholar, 176Eijkenaar F Emmert M Scheppach M Schöffski O Effects of pay for performance in health care: a systematic review of systematic reviews.Health Policy. 2013; 110: 115-130Google Scholar Explicit performance incentives encourage providers to focus on aspects of PHC that are unlikely to be incentivised by the global base payment and might be prone to quality skimping or underprovision. However, the current evidence suggests that improvements that result from pay-for-performance schemes are often less than anticipated.174Diaconu K Falconer J Verbel A Fretheim A Witter S Paying for performance to improve the delivery of health interventions in low- and middle-income countries.Cochrane Database Syst Rev. 2021; 5CD007899Google Scholar Financial incentives should be relatively low powered to prevent disproportionate focus on rewarded tasks and to ensure sustainability.177Campbell SM Reeves D Kontopantelis E Sibbald B Roland M Effects of pay for performance on the quality of primary care in England.NEJM. 2009; 361: 368-378Google Scholar, 178Mullen KJ Frank RG Rosenthal MB Can you get what you pay for? Pay-for-performance and the quality of healthcare providers.RAND J Econ. 2010; 41: 64-91Google Scholar, 179Steel N Maisey S Clark A Fleetcroft R Howe A Quality of clinical primary care and targeted incentive payments: an observational study.Br J Gen Pract. 2007; 57: 4494549-5-4494549-14Google Scholar, 180Holmstrom B Milgrom P Multitask principal-agent analyses: incentive contracts, asset ownership, and job design.J Law Econ Organ. 1991; 7: 242-252Google Scholar
Performance monitoring should happen alongside implementation of the blended payment model. Under capitation, the payment is divorced from activity, meaning a concerted effort needs to be made to monitor how well health-care providers are doing. Indeed, a key advantage of pay-for-performance is that it can contribute to better accountability, such as improved measurement of provider activity and performance, and a more informed dialogue between purchasers and providers.181Cashin C Chi Y-L Smith P Borowitz M Thomson S Paying for performance in health care. Implications for health system performance and accountability. Open University Press, England2014Google Scholar
For a blended provider payment system to create meaningful incentives that affect providers ' behaviours, adequate funding needs to flow through funding streams and not create conflicting incentives. Providers must also have the autonomy to manage funds and respond to incentives. Capitation payment rates on which a blended system is based should reflect adequate funding levels to purchase the inputs needed to deliver the package of PHC services according to quality standards laid out in national treatment guidelines. At the same time, payment levels must also align with the resources available from pooled public sources and the political priority placed on PHC. As funding to the health system overall grows, and as the skills of health workers to deliver the package of PHC services increase, capitated rates can be increased to channel a larger share of overall funding to PHC.
Capitation payments should be managed at the lowest level where they can be used effectively to provide the full range of services to address population health needs. In some systems, such as in Estonia182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar and England, this is a frontline PHC provider organisation. Other countries, including Ghana and Kenya, are experimenting with establishing groups or networks of PHC providers to manage capitation payments. These platforms can share some functions, such as information management and quality assurance, and close capacity gaps. Providing capitation payments to a multidisciplinary provider group has been shown to foster coordination across the continuum of care.166Cattel D Eijkenaar F Value-based provider payment initiatives combining global payments with explicit quality incentives: a systematic review.Med Care Res Rev. 2020; 77: 511-537Google Scholar At a higher level still, in Brazil and Chile, local government authorities manage capitated funds for the delivery of PHC, and individual health workers can receive bonuses when their team or facility achieves performance targets.55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar, 107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar In Thailand, capitation payments go to a contracting unit for primary care. More than likely, funds will need to be directed to multiple levels simultaneously to enable the provision of both individual-focused care and population-level services including essential public health functions ( see section 4).
Funding flows from multiple sources need to be harmonised to align the incentives for providers. Although it is usually not feasible ( or necessarily desirable) to merge all funding flows, a coordinated and deliberate payment system can help to achieve greater coherence at the provider level. A good example is Tanzania's system for providing direct facility financing using health-sector basket ( pooled) funding from donors who have agreed to finance the health sector budget through the central treasury.141Kapologwe NA Kalolo A Kibusi SM et al.Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol.Health Res Policy Syst. 2019; 17: 11Google Scholar
The way outpatient specialty and inpatient services are paid for can also influence the overall incentive environment for PHC providers. For example, if PHC providers are paid a fixed capitation payment, but hospitals are paid based on the volume of services provided, the potential adverse incentive of capitation payment to increase referrals is reinforced by the adverse incentive for hospitals to increase the volume of care, including admissions.55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar, 165Langenbrunner J Cashin C O'Dougherty S Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, USA2009Google Scholar As mentioned in section 4, additional policy measures might therefore be needed to harmonise incentives across the levels of care, including gatekeeping requirements to enforce referral guidelines, ring-fencing the payment pool for PHC, or introducing payment caps at the level of the hospital to reduce incentives for unnecessary admissions.183Tangcharoensathien V Limwattananon S Patcharanarumol W Thammatacharee J Jongudomsuk P Sirilak S Achieving universal health coverage goals in Thailand: the vital role of strategic purchasing.Health Policy Plan. 2015; 30: 1152-1161Google Scholar
An effective capitation-based blended payment is a sophisticated provider payment model that relies on a complex set of policies, implementation arrangements, and purchaser and provider management capacities. Reaching this stage requires a clear vision backed by strong political commitment, significant time, and consistent investment. As with the introduction of any new provider payment system, the responses of providers to the rollout of a capitation-based blended payment model can not be fully anticipated. However, their responses are likely to be different if the payment model is evolving from an input-based budget ( in which providers have little autonomy and might welcome the flexibility of capitation) or from fee-for-service payment ( in which providers have more control over their revenue and might resist the move to capitation).
Moving towards a blended payment model, as with any reform process, requires anticipation and deft management of complex political economies, collection and analysis of data to address emerging issues, and flexibility to address unintended consequences in a timely manner. This process can seem dauntingly complex—however, the alternative is to remain with a status quo that is failing to provide the incentive environment required for delivery of PHC to improve health outcomes and equity. Provider payment reform is incremental and rarely is there a perfect time to start.
Many payment systems have evolved to reach blended payment models in similar ways, regardless of their starting points. In most countries, the introduction of equity-orientated and efficiency-oriented payment system reforms starts with a basic population-based capitation model. Typically, these systems are transparent, involve simple per-capita payments, and are easy to administer in places where data automation is limited. Most payment systems then eventually introduce risk adjustments. Complexity continues to increase over time as additional payment methods are added.
Figure 11 presents the pathway of how countries can pursue the Commission's vision of a blended payment system, showing the interim steps in the evolution. Figure 11 also indicates the basic functions that should be strengthened over time to support payment reforms. Learning from other countries ' experiences can help countries committed to progressive policies to hasten the development of their own context-appropriate payment models.Figure 11Strategic pathway for moving to a blended, capitation-based paymentView Large Image Figure ViewerDownload Hi-res image Download ( PPT)
The trajectory towards a population-based payment model involves several concrete steps. First, establish a baseline capitation payment system. For capitation to promote equity and create clear incentives, the payment amount should be based on a formula that links the payment parameters ( base per-capita rate, number of enrollees linked to the provider, and any individual or provider-level adjustments) to a defined package of PHC services. Each payment parameter can range from simple to complex. They function as strategic levers to maximise the potential benefits of the payment system while minimising adverse incentives and unintended consequences.
Second, define the PHC package. As mentioned in section 1, defining a package of PHC services linked to capitation payment creates an opportunity for each country to clarify what its definition of PHC includes ( as well as setting boundaries between primary care, outpatient specialty services, and secondary care). Specifying what is included in the PHC package and where it is provided can drive shifts in service delivery priorities and promote the integration of vertical programmes into PHC.155Cashin C Gubanova O Kadyrova N et al.Primary health carePHC per capita payment systems.in: Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, WA2009Google Scholar The PHC package linked to capitation ( which may be a subset of the broader PHC package) can also be expanded to serve as the platform for financing essential medicines,155Cashin C Gubanova O Kadyrova N et al.Primary health carePHC per capita payment systems.in: Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, WA2009Google Scholar either directly or through an outpatient drug reimbursement scheme, because medicines are a key driver of out-of-pocket expenses in LMICs.
Third, manage enrolment. A capitation payment system relies on all individuals being enrolled ( registered) with a given provider for a fixed period. The assignment of a fixed and defined population to a single PHC provider is an advantage of the system. PHC services contribute to improving the health of communities by organising around populations rather than only serving individuals who actively seek health care. Individuals can be enrolled with providers through administrative assignment ( as defined by a geographical catchment area) or by their own choice ( known as open enrolment). Open enrolment during select time periods allows financing to support users ' choices; in principle, this creates incentives for providers to be responsive to patients and provide high-quality services.155Cashin C Gubanova O Kadyrova N et al.Primary health carePHC per capita payment systems.in: Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, WA2009Google Scholar, 184Mills A Bennett S Siriwanarangsun P Tangcharoensathien V The response of providers to capitation payment: a case-study from Thailand.Health Policy. 2000; 51: 163-180Google Scholar, 185Santos R Gravelle H Propper C Does quality affect patients ' choice of doctor? Evidence from England.Econ J. 2017; 127: 445-494Google Scholar
Fourth, adjust for risk levels. Risk adjustment is a correction tool that uses a measure of risk variation to compensate health providers appropriately for the expected costs of providing necessary services for their enrolled populations. The calculations account for variation in health need, typically by using data on different baseline characteristics such as levels of health, sex or gender, chronic disease risk, and socioeconomic status. Risk adjustment protects higher risk and sicker patients from the incentive providers have to avoid caring for them when their care is predicted to be especially costly. Other adjustments, such as for geographic area, might also be included if there are significant cost variations for delivering the same package of PHC services in different locations, such as in rural and remote areas where fixed costs for transportation or use might be higher.
Fifth, blend payment methods. Countries almost always find that the precise blend of payment changes as the system matures. Various factors, including history, culture, priorities within the PHC system, or shifting disease patterns in a country, can drive these changes.186Charlesworth A Davies A Dixon J Reforming payment for health care in Europe to achieve better value. Nuffield Trust, London2012Google Scholar In Estonia, for example, the relative contribution or blend of different payment methods ( capitation, fee-for-service, fixed basic allowance, and pay-for-performance) has evolved over time, as described in panel 15 and figure 12. In Aotearoa, New Zealand, similar evolutions are also occurring, as outlined in panel 16.Panel 15Development of the primary health-care ( PHC) payment system in EstoniaThe Commission's Estonia case study focused on the process through which the capitation-centred provider payment model for family doctors was developed after independence from the Soviet Union in 1991.182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Estonia is a high-income country with an ageing population of 1·3 million people. The country's health system has been lauded for achieving good health outcomes at low cost. Public funding represents the predominant source of health financing, constituting approximately three-quarters of total health expenditure.The current system has been evolving over nearly three decades. In the late 1990s, Estonia undertook major payment reforms in parallel with organisational changes to the health system. Everyone in the population was registered with a PHC provider, either a family doctor, general internist, or paediatrician. Family doctors worked as private practitioners contracted by the national health insurance fund. The previous fee-for-service system was replaced with a capitation system, initially based on a flat per-person rate that was subsequently age adjusted. The capitation rate was intended to cover the salaries of a practice's family doctor and a nurse, as well as a defined set of equipment and certain laboratory tests. A basic allowance covered the costs of equipment, facilities, and transportation. Some fee-for-service payments were retained for a defined list of diagnostic tests and procedures. An additional lump sum was provided to cover the expenses of family doctors working in rural areas.This new payment system was designed to incentivise family doctors to take more responsibility for diagnostics and treatment and provide continuity of care; the system also compensated doctors for the financial risks of caring for older people and working in more remote areas. Moving to capitation-based funding represented a major shift from the previous fee-for-service payment mechanism, in which doctors and health-care institutions were incentivised to perform a large number of diagnostic procedures. The shift in payment model was introduced along with a new organisational and contractual mechanism that has successfully promoted PHC while increasing the freedom and independence of PHC providers.The payment system has continued to mature as new elements are added, as shown in figure 12. In the 2000s, a voluntary pay-for-performance element was added that was designed to motivate family doctors to widen their scope to include more prevention services ( eg, childhood vaccinations) and chronic disease management ( eg, hypertension care). This reform was widely accepted by providers: the proportion of family doctors participating in the scheme rose from 50% in 2006, to 97% in 2014. In 2015, participation in this quality-focused bonus scheme finally became obligatory for all family doctors, and individual performance results became public information. The basic allowances have also increased to cover rising costs of management and information systems and to motivate individual providers to form groups and expand the scope of services offered.Figure 12Estonia's blended PHC payment system in 2003 and 2019Show full captionPHC=primary health care.View Large Image Figure ViewerDownload Hi-res image Download ( PPT) Panel 16Capitation in the reform of Aotearoa New Zealand's primary health-care ( PHC) systemThe Commission's case study on Aotearoa ( New Zealand) focused on capitation payment for general practitioners.187Cumming J Aotearoa New Zealand's PHC strategy: equity-enhancing in policy and in practice?. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Capitation was suggested as a way of paying PHC providers as far back as the 1930s, when the government embarked on a major reform to introduce free, integrated, comprehensive health care for the entire population. However, due to resistance from general practitioners, the capitation plan was scrapped and general practitioners remained as independent small businesses with their services funded by a fee-for-service government subsidy and out-of-pocket user fees. By the 1990s, the subsidy was funding only 20–30% of general practitioner costs, with the rest coming from user fees.In the early 2000s, the government developed a Primary Health Care Strategy, the first major PHC policy since the 1930s. The government established a new type of not-for-profit entity, the Primary Health Organisation, which enlisted PHC providers on a voluntary basis. This allowed the health system to shift to universal weighted capitation at the Primary Health Organisation level. The shift ensured that all citizens could receive subsidised care in a way that accounted for need. The move to capitation was also designed to control government expenditure on PHC and expand the range of services that could be delivered by nurses. Over time, the Primary Health Care Strategy enabled the government to increase PHC funding and allocate a greater proportion to Primary Health Organisations working with higher-need populations. Large decreases in unmet need for general practitioner services were observed in the first 5 years, including for Māori people.However, ongoing issues also persist. Although the funding was allocated using a risk-adjusted capitation formula, it insufficiently accounted for variation in needs related to ethnicity and deprivation. Despite a number of reviews, the formula has not been improved, in part because of concerns that further risk adjustment would create so-called winners and losers and undermine support amongst key groups. Instead, numerous ad-hoc changes have been made, resulting in complicated funding arrangements that can be confusing. There have also been concerns about continued user fees. Although they decreased initially, particularly for those on low incomes, the decreases were less than anticipated given the large increases in funding and the continued existence of charges might be blunting the provider incentives that were meant to be created by capitation. Major ongoing reforms to the structure and delivery of health services seek to address some of these challenges.188New Zealand Department of the Prime Minister and Cabinet. Our health and disability system: building a stronger health and disability system that delivers for all New Zealanders. Wellington: New Zealand, 2021.Google Scholar
The Commission's Estonia case study focused on the process through which the capitation-centred provider payment model for family doctors was developed after independence from the Soviet Union in 1991.182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Estonia is a high-income country with an ageing population of 1·3 million people. The country's health system has been lauded for achieving good health outcomes at low cost. Public funding represents the predominant source of health financing, constituting approximately three-quarters of total health expenditure.
The current system has been evolving over nearly three decades. In the late 1990s, Estonia undertook major payment reforms in parallel with organisational changes to the health system. Everyone in the population was registered with a PHC provider, either a family doctor, general internist, or paediatrician. Family doctors worked as private practitioners contracted by the national health insurance fund. The previous fee-for-service system was replaced with a capitation system, initially based on a flat per-person rate that was subsequently age adjusted. The capitation rate was intended to cover the salaries of a practice's family doctor and a nurse, as well as a defined set of equipment and certain laboratory tests. A basic allowance covered the costs of equipment, facilities, and transportation. Some fee-for-service payments were retained for a defined list of diagnostic tests and procedures. An additional lump sum was provided to cover the expenses of family doctors working in rural areas.
This new payment system was designed to incentivise family doctors to take more responsibility for diagnostics and treatment and provide continuity of care; the system also compensated doctors for the financial risks of caring for older people and working in more remote areas. Moving to capitation-based funding represented a major shift from the previous fee-for-service payment mechanism, in which doctors and health-care institutions were incentivised to perform a large number of diagnostic procedures. The shift in payment model was introduced along with a new organisational and contractual mechanism that has successfully promoted PHC while increasing the freedom and independence of PHC providers.
The payment system has continued to mature as new elements are added, as shown in figure 12. In the 2000s, a voluntary pay-for-performance element was added that was designed to motivate family doctors to widen their scope to include more prevention services ( eg, childhood vaccinations) and chronic disease management ( eg, hypertension care). This reform was widely accepted by providers: the proportion of family doctors participating in the scheme rose from 50% in 2006, to 97% in 2014. In 2015, participation in this quality-focused bonus scheme finally became obligatory for all family doctors, and individual performance results became public information. The basic allowances have also increased to cover rising costs of management and information systems and to motivate individual providers to form groups and expand the scope of services offered.
The Commission's case study on Aotearoa ( New Zealand) focused on capitation payment for general practitioners.187Cumming J Aotearoa New Zealand's PHC strategy: equity-enhancing in policy and in practice?. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Capitation was suggested as a way of paying PHC providers as far back as the 1930s, when the government embarked on a major reform to introduce free, integrated, comprehensive health care for the entire population. However, due to resistance from general practitioners, the capitation plan was scrapped and general practitioners remained as independent small businesses with their services funded by a fee-for-service government subsidy and out-of-pocket user fees. By the 1990s, the subsidy was funding only 20–30% of general practitioner costs, with the rest coming from user fees.
In the early 2000s, the government developed a Primary Health Care Strategy, the first major PHC policy since the 1930s. The government established a new type of not-for-profit entity, the Primary Health Organisation, which enlisted PHC providers on a voluntary basis. This allowed the health system to shift to universal weighted capitation at the Primary Health Organisation level. The shift ensured that all citizens could receive subsidised care in a way that accounted for need. The move to capitation was also designed to control government expenditure on PHC and expand the range of services that could be delivered by nurses. Over time, the Primary Health Care Strategy enabled the government to increase PHC funding and allocate a greater proportion to Primary Health Organisations working with higher-need populations. Large decreases in unmet need for general practitioner services were observed in the first 5 years, including for Māori people.
However, ongoing issues also persist. Although the funding was allocated using a risk-adjusted capitation formula, it insufficiently accounted for variation in needs related to ethnicity and deprivation. Despite a number of reviews, the formula has not been improved, in part because of concerns that further risk adjustment would create so-called winners and losers and undermine support amongst key groups. Instead, numerous ad-hoc changes have been made, resulting in complicated funding arrangements that can be confusing. There have also been concerns about continued user fees. Although they decreased initially, particularly for those on low incomes, the decreases were less than anticipated given the large increases in funding and the continued existence of charges might be blunting the provider incentives that were meant to be created by capitation. Major ongoing reforms to the structure and delivery of health services seek to address some of these challenges.188New Zealand Department of the Prime Minister and Cabinet. Our health and disability system: building a stronger health and disability system that delivers for all New Zealanders. Wellington: New Zealand, 2021.Google Scholar
LMICs considering shifting to a more strategic payment model for PHC need to consider when and how to embark on the process. The Commission emphasises that the right choices of when and how to transform the PHC payment model depend on the country context. Experience suggests that if a country is not ready ( with conducive political will and some basic functions in place), payment reforms can be disruptive and potentially harmful.
In many LICs, the priority issue is the amount of coordinated funding reaching PHC provider level. These countries should focus first and foremost on getting more funds to PHC providers that can be used flexibly to meet population health needs. This might involve changes to the funding allocation mechanism, as discussed in section 4. In other countries, strengthening basic functions alongside an assessment of the current provider payment system is an appropriate first step.156Cashin C Ankhbayar B Phuong HT et al.Assessing health provider payment systems: a practical guide for countries working toward universal health coverage.https: //www.jointlearningnetwork.org/wp-content/uploads/2019/11/JLN ProviderPayment MainGuide InteractivePDF.pdfDate accessed: July 18, 2021Google Scholar
Even a perfectly-designed capitation-based blended payment system can not work without basic supporting functions in place ( figure 11). These will need to develop and evolve as the payment system becomes more sophisticated. It is possible that digital technologies can help to support the evolution of the provider payment system but this remains to be seen ( appendix p 35). We describe the main basic supporting functions.
•Routine data capture and electronic record systems that are interoperable across datasets, ideally for the whole country, are needed to support complex payment systems. This is an iterative process: requiring data for payment leads to better data, which in turn allows for implementation of a more sophisticated payment system. The capacity to analyse and interpret data should be strengthened if policymakers are to act on data-driven evidence. Data are necessary for payment calculations and monitoring of population enrolment, population characteristics, and service delivery performance. The population enrolment list or database must be accurate because payments to providers under capitation are influenced by the number of individuals enrolled with that provider. The method of creating the list and giving providers access to it should be transparent so providers trust the list and their final payment amounts. Data are also necessary for population characteristics monitoring. To adjust population-based payment rates for need, detailed data on the key characteristics of the registered population are required. Last, data are necessary for service delivery performance monitoring because it is important to capture information on clinical care, health-care use, and patient experience to understand how well PHC providers are addressing population needs and to monitor undesirable behaviours, such as underprovision and excess referral. Performance monitoring should be aligned with the benefit package so that providers can be held to account on the services they deliver.•Giving providers more autonomy to make decisions about how to provide PHC supports their flexibility to respond to incentives.11Stenberg K Axelson H Sheehan P et al.Advancing social and economic development by investing in women's and children's health: a new global investment Framework.Lancet. 2014; 383: 133-154Google Scholar Fostering provider autonomy includes the acquisition of new skills, many of which might be non-clinical—for example to do with coordination and communication. It also necessitates building their capacities to understand and manage incoming resources. In systems where providers have little management autonomy or do not have the skills to manage new procedures, the results of new purchasing and payment methods will be either be diminished or perverse. For example, in Indonesia, the purchaser for the national health insurance system pays PHC providers by capitation. However, there are strict rules about how public providers can allocate those funds among staff payments and other operational costs.116Cashin C Bloom D Sparkes S Barroy H Kutzin J O'Dougherty S Aligning public financial management and health financing: sustaining progress toward universal health coverage. WHO, Geneva2017Google Scholar In addition, providers that receive funds from multiple revenue streams must know how to allocate and account for them separately. Introducing complicated rules without training providers to understand them greatly diminishes the potential of capitation payment systems to encourage better and more efficient use of resources for service delivery.•Public financial management systems must be flexible and straightforward. Many governments ' public finance management systems are notorious for their rigidity regarding the use of funds and the complexity of their accounting and financial management requirements. Traditional public finance management systems might even prohibit prepayment to PHC providers, which is an essential design feature of capitation. However, when health facilities have strong financial management capacity and authority to make some financial management decisions, they are more likely to adjust service provision and deploy inputs based on the needs of the population.115WHOBuilding strong public financial management systems towards universal health coverage: key bottlenecks and lessons learnt Regional workshop on PFM for sustainable financing for health in Africa. WHO, Nairobi2018Google Scholar Payment system reform also requires simplification, by reducing administrative layers and burdens, and harmonising funding flows. This is key to ensuring that resources reach facilities on time and in full, and are appropriately tracked. Delays can be corrosive. In Ghana, for example, delays in fund transfers eroded trust in the capitation system.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar One potential solution is to establish facility bank accounts, which might require changing the legal status of facilities within the public finance management system, to enable direct payments to facilities,128Primary Health Care Performance InitiativeImprovement strategies model: funds.https: //improvingphcPHC.org/sites/default/files/Funds% 20last% 20updated% 2012.20.2019.pdfDate: 2019Date accessed: July 3, 2021Google Scholar as has been tried in Tanzania,190Barroy H Kabaniha G Boudreaux C Cammack T Bain N Leveraging public financial management for better health in Africa: key bottlenecks and opportunities for reform. 2019. World Health Organization, Geneva2019Google Scholar Uganda,128Primary Health Care Performance InitiativeImprovement strategies model: funds.https: //improvingphcPHC.org/sites/default/files/Funds% 20last% 20updated% 2012.20.2019.pdfDate: 2019Date accessed: July 3, 2021Google Scholar and Nigeria.128Primary Health Care Performance InitiativeImprovement strategies model: funds.https: //improvingphcPHC.org/sites/default/files/Funds% 20last% 20updated% 2012.20.2019.pdfDate: 2019Date accessed: July 3, 2021Google Scholar•The purchaser—whether it is the government or a social health insurance agency—should have the institutional authority and technical capability to enter into legally binding agreements with health-care providers that specify the characteristics and minimum requirements of contracted providers, services that providers will deliver, the methods and terms of payment, reporting requirements, and processes to resolve disputes.156Cashin C Ankhbayar B Phuong HT et al.Assessing health provider payment systems: a practical guide for countries working toward universal health coverage.https: //www.jointlearningnetwork.org/wp-content/uploads/2019/11/JLN ProviderPayment MainGuide InteractivePDF.pdfDate accessed: July 18, 2021Google Scholar
The experiences of countries that have attempted reforms of provider payment systems also highlight the need for PHC providers to be involved in the design of policies and adequately sensitised so that they understand the changes and lend their support to implementation.191Robyn PJ Bärnighausen T Souares A et al.Provider payment methods and health worker motivation in community-based health insurance: a mixed-methods study.Soc Sci Med. 2014; 108: 223-236Google Scholar, 192Agyei-Baffour P Oppong R Boateng D Knowledge, perceptions and expectations of capitation payment system in a health insurance setting: a repeated survey of clients and health providers in Kumasi, Ghana.BMC Public Health. 2013; 131220Google Scholar Patients also need to be given information on their eligibility and entitlements. A method to monitor when providers incur excessive financial risks is required, and risk mitigation strategies considered. Finally, it is important to have a policy on the portability of benefits to determine how patients can access services when away from their registered facility and how their temporary providers will be paid.
Introducing a new provider payment system such as capitation is a highly technical endeavour. It is also a complex political process because making such major system-wide changes affects many of the stakeholders in the health system, including every PHC provider and patient served by the health system. It requires anticipating the effect of the new system on major stakeholders, including medical professionals ( both general practitioners and specialists), social health insurance administrators, private sector providers, and the pharmaceutical industries. Introducing reforms requires significant interagency coordination within the government and possibly with donors.
The political economy challenges depend on a country's starting position. If the status quo is input-based budgets, a key stakeholder to engage is the ministry of finance because of its central role in defining the budget approach and public financial management rules. In countries with institutionalised fee-for-service, health providers might try to impede the reform, because population-based payment involves a transfer of risk to providers and is often perceived to be less lucrative for them as income is no longer tied to services.
The various possible pitfalls a country can encounter when attempting to change provider payment systems are evident in the experiences of several countries. The American Medical Association has opposed capitation ( amongst other reforms) since the 1930s, when primary care physicians created a new insurance company to prevent hospital insurance plans from entering the primary care sector and influencing control over fees.193Moseley 3rd, GB The US health care non-system, 1908–2008.AMA J Ethics. 2008; 10: 324-331Google Scholar, 194Hoffman C National health insurance. A brief history of reform efforts in the US. The Henry J Kaiser Family Foundation, Menlo Park, CA2009Google Scholar Medical associations in South Korea ( where all physicians are paid on a fee-for-service basis) have complained about price regulation by the government and successfully pushed back on cost control reforms, such as diagnostic related groups and global budgets.195Yi I Sohn H-S Kim T Linking state intervention and health equity differently: the universalization of health care in South Korea and Taiwan.Korea Observer. 2015; 46: 517-549Google Scholar, 196Barber S Luca L Paul O Price setting and price regulation in health care lessons for advancing universal health coverage: lessons for advancing universal health coverage. WHO and OECD, Geneva2019Google Scholar Providers ' resistance has been influential in thwarting or undermining reforms in Taiwan,195Yi I Sohn H-S Kim T Linking state intervention and health equity differently: the universalization of health care in South Korea and Taiwan.Korea Observer. 2015; 46: 517-549Google Scholar USA,193Moseley 3rd, GB The US health care non-system, 1908–2008.AMA J Ethics. 2008; 10: 324-331Google Scholar Turkey,197Bump JB Sparkes SP A political economy analysis of Turkey's health transformation program. World Bank, Washington DC, WA2014Google Scholar and Ghana ( panel 17). Patient pushback ( often fuelled by provider activism) against limits to provider choice under capitation has been documented in some of these countries.Panel 17Lessons learnt from the capitation pilot in GhanaThe Commission's Ghana case study examined a pilot of a capitation scheme in one region of the country between 2012 and 2016.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar The national health insurance scheme was introduced in Ghana in 2003, to replace the so-called cash and carry system based on user fees that had prevailed in the country after a free health care for all policy was abolished in 1969. The national health insurance scheme started with a fee-for-service payment for all covered services including primary health care ( PHC), but that resulted in cost escalations that threatened the sustainability of the scheme. There was, for example, a large increase in annual spending, in the first 5 years of the scheme, driven by increases in the number of claims per insured member.198Wang H Otoo N Dsane-Selby L Ghana national health insurance scheme: improving financial sustainability based on expenditure review. World Bank, Washington, DC2017Google Scholar, 199National Health Insurance AuthorityNHIS Annual report 2009.http: //www.nhis.gov.gh/files/1 ( 1).pdfDate: 2009Date accessed: July 15, 2021Google Scholar In response, the national health insurance authority introduced diagnostic related groups for outpatient and inpatient services and itemised medicine fees in 2008. However, even though the number of claims per member was reduced by 13%, overall costs kept rising and the complicated claims management process led to delays in processing claims.In 2012, the national health insurance authority piloted a capitation payment system for PHC in the Ashanti region. However, the pilot was suspended after 5 years and various challenges. Agitations and protests by providers had begun at the start of the reform.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Their objections were especially consequential because 2012 was an election year and the government was highly sensitive to any social unrest. In response to the providers ' agitation, the Ministry of Health and the national health insurance authority made major policy compromises, including a reduction in the package of services and a 22% increase in the per capita rate.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar These and other compromises could possibly have been avoided if the implementers had considered various political, social, and economic factors from the outset. For example, they might have faced less opposition if they had chosen a pilot site that was less politically sensitive and not dominated by politically powerful private health care providers.Many lessons were learned from the pilot about stakeholder engagement and building trust among providers and users. It also showed the importance of the supporting systems needed to implement capitation payment, which continues to be among policy options considered by the national health insurance for future reforms. The experience of the capitation pilot has also triggered discussions about service delivery reforms to form PHC networks to close gaps in provider clinical capacity, which also posed a challenge to the successful implementation of capitation payment.
The Commission's Ghana case study examined a pilot of a capitation scheme in one region of the country between 2012 and 2016.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar The national health insurance scheme was introduced in Ghana in 2003, to replace the so-called cash and carry system based on user fees that had prevailed in the country after a free health care for all policy was abolished in 1969. The national health insurance scheme started with a fee-for-service payment for all covered services including primary health care ( PHC), but that resulted in cost escalations that threatened the sustainability of the scheme. There was, for example, a large increase in annual spending, in the first 5 years of the scheme, driven by increases in the number of claims per insured member.198Wang H Otoo N Dsane-Selby L Ghana national health insurance scheme: improving financial sustainability based on expenditure review. World Bank, Washington, DC2017Google Scholar, 199National Health Insurance AuthorityNHIS Annual report 2009.http: //www.nhis.gov.gh/files/1 ( 1).pdfDate: 2009Date accessed: July 15, 2021Google Scholar In response, the national health insurance authority introduced diagnostic related groups for outpatient and inpatient services and itemised medicine fees in 2008. However, even though the number of claims per member was reduced by 13%, overall costs kept rising and the complicated claims management process led to delays in processing claims.
In 2012, the national health insurance authority piloted a capitation payment system for PHC in the Ashanti region. However, the pilot was suspended after 5 years and various challenges. Agitations and protests by providers had begun at the start of the reform.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Their objections were especially consequential because 2012 was an election year and the government was highly sensitive to any social unrest. In response to the providers ' agitation, the Ministry of Health and the national health insurance authority made major policy compromises, including a reduction in the package of services and a 22% increase in the per capita rate.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar These and other compromises could possibly have been avoided if the implementers had considered various political, social, and economic factors from the outset. For example, they might have faced less opposition if they had chosen a pilot site that was less politically sensitive and not dominated by politically powerful private health care providers.
Many lessons were learned from the pilot about stakeholder engagement and building trust among providers and users. It also showed the importance of the supporting systems needed to implement capitation payment, which continues to be among policy options considered by the national health insurance for future reforms. The experience of the capitation pilot has also triggered discussions about service delivery reforms to form PHC networks to close gaps in provider clinical capacity, which also posed a challenge to the successful implementation of capitation payment.
In addition to the wider context, specific design characteristics of the proposed changes can also hamper or foster reform efforts. In HICs, capitation has often been implemented as part of a larger health reform, such as a shift towards family medicine.200Gérvas J Fernández MP Cobos LP Sánchez RP Viente años de reforma de la Atención Primaria en España. Valoración para un aprendizaje por acierto/error: Ministerio Sanidad y Consumo.http: //equipocesca.org/new/wp-content/uploads/2010/08/20-anos-de-reforma-de-la-ap-en-espana.pdfDate: 2005Date accessed: June 18, 2021Google Scholar, 201Hsiao W Done N Implementation of social health insurance in Estonia: a case study. World Bank, Washington, DC2009Google Scholar, 202Dan S, Savi R. Payment systems and incentives in primary care in transition healthcare systems: Implications of recent reforms in Estonia and Romania. European Consortium for Political Research Graduate Conference; Bremen; July 12, 2012.Google Scholar This was the case in Estonia, where the early establishment of a strong association of family doctors helped build support for PHC reform. In LMICs, capitation has more often been introduced as part of financing, rather than delivery, reforms. Several countries have combined the introduction of a capitation-based system with the creation of national health insurance programmes; examples include Indonesia,203Pisani E Olivier Kok M Nugroho K Indonesia's road to universal health coverage: a political journey.Health Pol Plan. 2017; 32: 267-276Google Scholar Thailand,204Hort K Gilbert K Basnayaka P Annear PL Strategies to strengthen referral from primary care to secondary care in low-and middle-income countries. Regional Office for South-East Asia, World Health Organization, Manila2019Google Scholar and Kyrgyzstan.205Giuffrida A Jakab M Dale EM Toward universal coverage in health: the case of the state guaranteed benefit package of the Kyrgyz Republic. World Bank, Washington, DC2013Google Scholar
Changing the provider payment system also requires engaging with health system users. Many will have concerns, such as about whether the new system would limit their choices or introduce new forms of gatekeeping. However, one of the key potential benefits of capitation is fostering longer-term relationships between health system users and PHC providers; in principle this can bring more personalised care management and attention to prevention.155Cashin C Gubanova O Kadyrova N et al.Primary health carePHC per capita payment systems.in: Langenbrunner J Cashin C O'Dougherty S Designing and implementing health care provider payment systems: how-to manuals. The World Bank, Washington, DC, WA2009Google Scholar Maximising this benefit and minimising perceived limits on choice require concerted patient education efforts and facilitating informed choice.
As is discussed further in section 6, advocates for changing the provider payment system can define political strategies to strengthen support and neutralise opposition to the proposed reforms.197Bump JB Sparkes SP A political economy analysis of Turkey's health transformation program. World Bank, Washington DC, WA2014Google Scholar, 206Reich MR Campos PA A guide to applied political analysis for health reform.https: //cdn1.sph.harvard.edu/wp-content/uploads/sites/2216/2020/08/Guide-Applied-Political-Analysis-final-2020.08.29-FINAL.pdfDate: 2020Date accessed: September 1, 2021Google Scholar
Thus far, our discussion of incentives has been focused on PHC provider organisations. Health care is delivered by individuals or teams of health workers; therefore, getting individual incentives right means health workers will be motivated to provide quality care and refrain from engaging in dual practice. Because community health workers have a vital role in the PHC system of many countries, panel 18 addresses the question of how this cadre of health worker should be paid.Panel 18Paying community health workersWHO recommends that community health workers should be remunerated for their work “ with a financial package commensurate to the job demands, complexity, number of hours, training, and roles that they undertake ”.207Cometto G Ford N Pfaffman-Zambruni J et al.Health policy and system support to optimise community health worker programmes: an abridged WHO guideline.Lancet Glob Health. 2018; 6: e1397-e1404Google Scholar This of course leaves open the question of how community health workers should be paid. Before addressing this question, it is important to highlight that community health workers in many low-income to middle-income countries feel they are underpaid and poorly compensated for their time and effort, and their pay is often delayed.208Perry HB Perry HB Health for the People: national community health programs from Afghanistan to Zimbabwe. United States Agency for International Development, Washington2021Google ScholarMost community health worker programmes offer some kind of financial incentive, with the choice between salary, monthly payments, or performance-based payments.209Colvin CJ Hodgins S Perry HB Community health workers at the dawn of a new era: 8. Incentives and remuneration.Health Res Policy Syst. 2021; 19: 112-125Google Scholar Monthly payments are often a way of avoiding giving further benefits associated with salaried government employees. It is notable that Ethiopia, Ghana, Malawi, and Nigeria have large programmes in which community health workers have the status of formal civil servants. Whether community health workers should be paid by salary or performance-based financial incentives must consider more than effectiveness. However, even if we focus on the narrow question of effectiveness, we are unaware of any studies that have compared the performance of community health workers under these two alternative ways of paying.By contrast, there is a growing body of evidence that suggests some types of performance-based financial incentives are more effective than others in improving delivery outcomes of community health-worker services.210Gadsden T Mabunda SA Palagyi A et al.Performance-based incentives and community health workers ' outputs, a systematic review.Bull World Health Organ. 2021; 99: 805-818Google Scholar Large payments appear to be more effective than small ones, but they tend to shift effort away from non-incentivised activities. Giving performance payments to both community health workers and supervisors, and combining incentives with information to the community have been shown to be effective. Financial incentives have not worked when community health workers had limited control over the incentivised task, there were complex rules around disbursement of the incentives, and the focus was on selling products to poor households. Relatedly, there is good evidence that non-financial incentives ( social recognition, trust, respect, and opportunities for growth and career advancement) can improve community health workers ' performance and reduce attrition.211Kok MC Dieleman M Taegtmeyer M et al.Which intervention design factors influence performance of community health workers in low-and middle-income countries? A systematic review.Health Policy Plan. 2015; 30: 1207-1227Google Scholar, 212Ashraf N Bandiera O Jack BK No margin, no mission? A field experiment on incentives for public service delivery.J Public Econ. 2014; 120: 111-117Google Scholar, 213Bernal P Martinez S In-kind incentives and health worker performance: Experimental evidence from El Salvador.J Health Econ. 2020; 70102267Google Scholar, 214Pallas SW Minhas D Pérez-Escamilla R Taylor L Curry L Bradley EH Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability?.Am J Public Health. 2013; 103: e74-e82Google ScholarFinancial incentives for community health workers need to be approached with caution, particularly the exclusive use of them. Although they can be effective, there is also scope for unintended consequences. Such a conclusion is reflected in WHO's suggestion that community health workers should not be paid “ exclusively or predominantly according to performance-based incentives ”.215WHOWHO guideline on health policy and system support to optimize community health worker programmes. WHO, Geneva2018Google Scholar
WHO recommends that community health workers should be remunerated for their work “ with a financial package commensurate to the job demands, complexity, number of hours, training, and roles that they undertake ”.207Cometto G Ford N Pfaffman-Zambruni J et al.Health policy and system support to optimise community health worker programmes: an abridged WHO guideline.Lancet Glob Health. 2018; 6: e1397-e1404Google Scholar This of course leaves open the question of how community health workers should be paid. Before addressing this question, it is important to highlight that community health workers in many low-income to middle-income countries feel they are underpaid and poorly compensated for their time and effort, and their pay is often delayed.208Perry HB Perry HB Health for the People: national community health programs from Afghanistan to Zimbabwe. United States Agency for International Development, Washington2021Google Scholar
Most community health worker programmes offer some kind of financial incentive, with the choice between salary, monthly payments, or performance-based payments.209Colvin CJ Hodgins S Perry HB Community health workers at the dawn of a new era: 8. Incentives and remuneration.Health Res Policy Syst. 2021; 19: 112-125Google Scholar Monthly payments are often a way of avoiding giving further benefits associated with salaried government employees. It is notable that Ethiopia, Ghana, Malawi, and Nigeria have large programmes in which community health workers have the status of formal civil servants. Whether community health workers should be paid by salary or performance-based financial incentives must consider more than effectiveness. However, even if we focus on the narrow question of effectiveness, we are unaware of any studies that have compared the performance of community health workers under these two alternative ways of paying.
By contrast, there is a growing body of evidence that suggests some types of performance-based financial incentives are more effective than others in improving delivery outcomes of community health-worker services.210Gadsden T Mabunda SA Palagyi A et al.Performance-based incentives and community health workers ' outputs, a systematic review.Bull World Health Organ. 2021; 99: 805-818Google Scholar Large payments appear to be more effective than small ones, but they tend to shift effort away from non-incentivised activities. Giving performance payments to both community health workers and supervisors, and combining incentives with information to the community have been shown to be effective. Financial incentives have not worked when community health workers had limited control over the incentivised task, there were complex rules around disbursement of the incentives, and the focus was on selling products to poor households. Relatedly, there is good evidence that non-financial incentives ( social recognition, trust, respect, and opportunities for growth and career advancement) can improve community health workers ' performance and reduce attrition.211Kok MC Dieleman M Taegtmeyer M et al.Which intervention design factors influence performance of community health workers in low-and middle-income countries? A systematic review.Health Policy Plan. 2015; 30: 1207-1227Google Scholar, 212Ashraf N Bandiera O Jack BK No margin, no mission? A field experiment on incentives for public service delivery.J Public Econ. 2014; 120: 111-117Google Scholar, 213Bernal P Martinez S In-kind incentives and health worker performance: Experimental evidence from El Salvador.J Health Econ. 2020; 70102267Google Scholar, 214Pallas SW Minhas D Pérez-Escamilla R Taylor L Curry L Bradley EH Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability?.Am J Public Health. 2013; 103: e74-e82Google Scholar
Financial incentives for community health workers need to be approached with caution, particularly the exclusive use of them. Although they can be effective, there is also scope for unintended consequences. Such a conclusion is reflected in WHO's suggestion that community health workers should not be paid “ exclusively or predominantly according to performance-based incentives ”.215WHOWHO guideline on health policy and system support to optimize community health worker programmes. WHO, Geneva2018Google Scholar
One frequently overlooked observation is that financial incentives generated by the provider payment mechanism at the organisation level might not be passed on to individuals. It depends on how individual health workers are paid. For example, pay-for-performance can provide a strong incentive at the provider level, but if most of the health workers are paid a flat salary, the effect on individual motivation might be less than expected. In low-income countries, salary levels are clearly important for health worker motivation but as influential perhaps are the delays in the monthly payment of salaries that are commonplace.
Because of the constraints of any payment system, the way in which services are provided depends to a large degree on the training and professionalism of the clinical workforce. It is essential that payment systems support and reinforce the professionalism of staff and their commitment to providing high-quality care. If the design of payment systems undermines professionalism by, for example, incentivising overprovision or discouraging continuity of care, staff can become demotivated.216Gravelle H Sutton M Ma A Doctor Behaviour under a pay for performance contract: treating, cheating and case finding?.Econ J. 2010; 120: 129-156Google Scholar This is one reason why representative clinicians should be involved in the design of payment systems.
Health workers place great stock in their strong culture of professionalism, often supported and cultivated during training.217Roland M Rao SR Sibbald B et al.Professional values and reported behaviours of doctors in the USA and UK: quantitative survey.BMJ Qual Saf. 2011; 20: 515-521Google Scholar This culture includes an orientation to the needs of patients, periodic self-reflection, and peer review. This relates to the importance of preserving provider autonomy. Similarly, there are direct non-financial incentives that can improve quality of care, such as opportunities for providers to share data on their performance with other professionals or with the public,218Prang KH Maritz R Sabanovic H Dunt D Kelaher M Mechanisms and impact of public reporting on physicians and hospitals ' performance: a systematic review ( 2000–2020).PLoS One. 2021; 16e0247297Google Scholar and social recognition.212Ashraf N Bandiera O Jack BK No margin, no mission? A field experiment on incentives for public service delivery.J Public Econ. 2014; 120: 111-117Google Scholar Health workers appreciate having data that validates their perceptions that they are doing a good job; comparing them with their peers can be a powerful incentive to improve their practices.
Progressive universalism, in which pooled funds should first be used to cover PHC to reduce out-of-pocket payments and replace the lost financing, requires action across all the health financing functions. In particular, removing financial barriers for PHC involves more than just changing user fees policy. It means ensuring patients do not face informal fees and are not sent to pharmacies to purchase medicines because public health providers are under-resourced. Provider payment rates and health worker salaries must be high enough to eliminate the need for user fees and informal payments. In this sense, provider payment policy is integral to the elimination of user fees and informal payments for PHC. In some countries, where escalating health expenditure from excessive use of services is a key concern, there might be a role for cost sharing but its effect on people with the lowest socioeconomic status should be carefully considered and mitigating measures put in place.
A key benefit of reducing out-of-pocket payments for PHC is to incentivise greater use of cost-effective health interventions, particularly amongst those with the greatest health needs. However, in some contexts, removing user fees is not sufficient to meaningfully expand financial access to care. Various programmes in LMICs have therefore introduced additional financial incentives for patients to use highly effective PHC services, such as immunisations and antenatal care. There is good evidence that offering cash or other financial incentives increases use of primary care services—although whether use translates into improved health outcomes is less clear.219Gopalan SS Mutasa R Friedman J Das A Health sector demand-side financial incentives in low- and middle-income countries: a systematic review on demand- and supply-side effects.Soc Sci Med. 2014; 100: 72-83Google Scholar, 220Lagarde M Haines A Palmer N Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review.JAMA. 2007; 298: 1900-1910Google Scholar Incentivising use of PHC will be more effective when the services are more readily available and of high quality. If the policy objective is to increase use, demand-side financial incentives should be considered before changes to provider incentives. However, there is little point in increasing demand for PHC if the available services are not ready or of sufficient quality to meet the population's needs.
This section has presented the Commission's view that provider payment for PHC should be based on a blended payment model, adapted to each context but with capitation at its centre. It has presented a strategic pathway for countries to progress towards this model, recognising that each country has its own unique starting point. It has recognised that incentive policies for providers and users are linked, and the crucial importance of simultaneously moving towards an elimination of user fees and informal payments for PHC. Progressing this vision requires mobilisation of additional resources for health, allocating these resources to PHC, and ensuring that they work their way through the public finance management system to reach frontline service providers. The success of this technical strategy depends on a political strategy to set the vision, understand the interests of different stakeholders, and actively manage these interests.
Transforming financing to support efficient and equitable PHC is often approached as a technical problem. Political and socioeconomic factors affecting financing reforms are frequently described as bottlenecks, barriers, or contextual factors. However, as has been highlighted throughout the report, the Commission recognises that these political economy elements are in fact central to any effort to understand, improve, or reform PHC financing.
In this section, we make the case that political economy analysis must be undertaken in conjunction with technical analysis and strategising for PHC financing reform, as part of a national mapping of the PHC financing ecosystem ( section 7). This integration is an important first step in resolving some fundamental questions, including: if PHC is the best approach to achieve UHC, why is it not systematically and adequately prioritised in national budgets? And why are purchasing and other health financing reforms successfully implemented in some countries, and resisted in others?
At its core, political economy brings together systematic explorations of politics and economics and power dynamics between stakeholder groups. Different schools of thought have focused on the so-called economy of politics, the economic constraints influencing political decisions, or understanding how the political context shapes the implementation of economic policy. The materialist approach, for example, focuses on the material conditions of a society's mode of production and argues that these determine how politics, economics, and social processes evolve.221Coburn D Health and health care: a political economy perspective.in: Bryant T Raphael D Rioux M Staying alive: Critical perspectives on health, illness, and health care. Second edition ed. Canadian Scholars ' Press Inc, Toronto2010: 65-91Google Scholar The new political economy approach states that policies can be analysed through the prism of neoclassical economics.222Whiteslide H Capitalist political economy: thinkers and theories.First edition. Routledge, London2020Google Scholar Other scholars take an actor-based approach, seeking to identify the winners and losers from policy processes by studying incentive structures influenced by economic interests. The laws and political conditions that shape the material world change over time, thus political economy is essentially an historical science.223Engels F Herrn Eugen Dühring's Umwälzung der Wissenschaft. Genossenschafts-Buchdruckerei, Leipzig1878Google Scholar
Drawing on these traditions, political economy analysis in the health policy field has tended to focus on politics,224Campos P Reich M Political analysis for health policy implementation.Health Syst Reform. 2019; 5: 224-235Google Scholar, 225Sparkes SP Bump JB Özçelik EA Political economy analysis for health financing reform.Health Syst Reform. 2019; 5: 183-194Google Scholar particularly on power relations among different interest groups and their relative abilities to influence reforms.225Sparkes SP Bump JB Özçelik EA Political economy analysis for health financing reform.Health Syst Reform. 2019; 5: 183-194Google Scholar, 226Roberts M Hsiao W Berman P Reich M Getting health reform right: a guide to improving performance and equity. Oxford University Press, New York, NY2008Google Scholar, 227Pierson P The new politics of the welfare state.World Politics. 1996; 48: 143-179Google Scholar Political economy analysis in health has also tended to analyse the outcomes of processes at a point in time and with a focus on a particular policy or specific issue, typically examining either the contestation and coalitions among interested parties that drive health system operations and reforms,226Roberts M Hsiao W Berman P Reich M Getting health reform right: a guide to improving performance and equity. Oxford University Press, New York, NY2008Google Scholar or the nature and strength of political institutions that could stop the legislative process that underpins the enactment of reform in political decision-making.105Sparkes SP Bump JB Reich MR Political strategies for health reform in Turkey: extending veto point theory.Health Systems Reform. 2015; 1: 263-275Google Scholar, 228Croke K Mohd Yusoff MB Abdullah Z et al.The political economy of health financing reform in Malaysia.Health Policy Plan. 2019; 34: 732-739Google Scholar Some authors have argued that the focus on political dynamics is too narrow229Hudson D Leftwich A From political economy to political analysis. developmental leadership program, Birmingham2014https: //res.cloudinary.com/dlprog/image/upload/research-paper-25-from-political-economy-to-political-analysisDate accessed: December 5, 2021Google Scholar and that understanding the roles of individuals within political structures has frequently been overemphasised.
Political economy analysis is also useful as a broader frame that examines the context, structures, and relationships that generate systemic features; what Jeremy Shiffman, a political scientist, focusing on the politics and global health governance of health policy-making in low-income countries calls the “ enduring political and social arrangements not easily altered by the actions of individuals ”.230Shiffman J Political Context and Health Financing Reform.Health Syst Reform. 2019; 5: 257-259Google Scholar
In this section, the Commission takes a relational view of political economy analysis. Our approach focuses on identifying how key actors—individuals, social groups, organisations, governments, and other stakeholders—relate to each other over time in determining access to, and distribution of power and resources, and how economic and social factors structurally influence these relationships. Applying political economy analysis to PHC financing helps to understand why resources for health are raised and allocated in particular ways to PHC for example, and what competition and contestation occurs throughout these processes. We conclude that political economy analysis has practical value in seeking to explain why efforts to improve efficiency and equity of PHC financing reforms have faced challenges, and to identify prospectively feasible strategies for particular political and socioeconomic contexts. Key messages from Section 6 are presented in panel 19.Panel 19Political economy of primary health care ( PHC) financing–key messages•Political, sociocultural, and economic conditions are as important as technical elements in the design and implementation of efficient and equitable financing for PHC. These political economy factors represent both constraints and opportunities.•Advancing financing for PHC that is people centred relies on politically informed technical strategies, meaning that policy making in PHC financing and reform must be underpinned by political economy analysis.•Prioritising PHC is possible at every income level and in any type of political governance model, given the presence of effective political alliances and socioeconomic conditions.•Designing politically informed technical strategies requires navigating the evolving political economy context. Political economy analysis can inform the adjustment of the technical strategies to identify the pathways and challenges to the proposed change, taking the long view, and identifying the structural social or economic so-called red lines to be worked around.•Developing PHC financing policy ( whether incremental adaptations or a substantial transformation) and ensuring strategic investment in PHC require coherent policy aligned with the interests of key actors through collaboration and building coalitions among stakeholders ( leaders, politicians, clinicians, technocrats, donors, and civil society representatives) and across sectors. This development might require achieving consensus or strategic compromise on how to expand access to PHC.•Having a clearly articulated long-term vision is essential for making progress towards efficient and equitable PHC financing. Consistency, adaptation and staying on course are required when countries pursue long-term reforms, while retaining flexibility to take advantage of opportunities for change created by political and socioeconomic events such as political transitions and shocks, or emerging alliances.•Sequencing is key. Planners must have the technical fundamentals and strategies ready in anticipation of windows of opportunity, which arise as a result of political dynamics and social and economic forces.
•Political, sociocultural, and economic conditions are as important as technical elements in the design and implementation of efficient and equitable financing for PHC. These political economy factors represent both constraints and opportunities.•Advancing financing for PHC that is people centred relies on politically informed technical strategies, meaning that policy making in PHC financing and reform must be underpinned by political economy analysis.•Prioritising PHC is possible at every income level and in any type of political governance model, given the presence of effective political alliances and socioeconomic conditions.•Designing politically informed technical strategies requires navigating the evolving political economy context. Political economy analysis can inform the adjustment of the technical strategies to identify the pathways and challenges to the proposed change, taking the long view, and identifying the structural social or economic so-called red lines to be worked around.•Developing PHC financing policy ( whether incremental adaptations or a substantial transformation) and ensuring strategic investment in PHC require coherent policy aligned with the interests of key actors through collaboration and building coalitions among stakeholders ( leaders, politicians, clinicians, technocrats, donors, and civil society representatives) and across sectors. This development might require achieving consensus or strategic compromise on how to expand access to PHC.•Having a clearly articulated long-term vision is essential for making progress towards efficient and equitable PHC financing. Consistency, adaptation and staying on course are required when countries pursue long-term reforms, while retaining flexibility to take advantage of opportunities for change created by political and socioeconomic events such as political transitions and shocks, or emerging alliances.•Sequencing is key. Planners must have the technical fundamentals and strategies ready in anticipation of windows of opportunity, which arise as a result of political dynamics and social and economic forces.
The Commission builds on the application of political economy analysis to health financing by explicitly considering broader social, political, and economic features of a context that can influence the success or failure of PHC financing functions and reform efforts, as well as their evolution.
Our political economy analysis framework, shown in figure 13, takes into consideration three domains that influence financing for PHC. First, politics: including the range of actors ( individuals, formal and informal organisations, and institutions) and their respective power, their relationships and contracts, their legitimacy, as well as contestation leading to the enactment of policies. Second, social conditions: encompassing social values, informal networks, class, caste, or other social constructs that can influence, for example, the options for distribution or redistribution of resources, including acceptance of, or resistance to, reforms such as greater pooling of resources. Third, economic conditions: including a country's level of economic development, production structures, levels of taxation and levels of aid, that facilitate or hamper the mobilisation of resources to PHC.Figure 13A political economy analysis conceptual framework for health financing reformView Large Image Figure ViewerDownload Hi-res image Download ( PPT)
These domains are interdependent. Further, they are characterised by dynamic structures and processes that evolve over time—sometimes gradually and in other cases rapidly. Each is discussed in more detail in relation to particular financing functions.
Politics and political conditions have crucial roles in explaining individuals ' and institutions ' behaviours. Three key political conditions influence the success of PHC financing initiatives in LMICs: the drivers of change, the mix of political actors, and the historical roots of the existing PHC financing system.
Change can be driven by different actors who represent various political powers, economic interests, or social movements. In some settings, such as Brazil and Costa Rica, strengthening PHC financing has been part of a consistent political drive to guarantee basic human rights and equity put forward by social movements that represent, or advocate for the interests of, grassroots populations, including poorer and marginalised groups.231VanderZanden A Pesec M Abrams M et al.What does community-oriented PHC look like? Lessons from Costa Rica.https: //www.commonwealthfund.org/publications/case-study/2021/mar/community-oriented-primary-care-lessons-costa-ricaDate: 2021Date accessed: July 30, 2021Google Scholar In both countries, providing essential public services, including investing in PHC, became part of the social contract between the state and its citizens and was supported by a diverse coalition of actors and enshrined in their constitutions.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar, 232Pesec M Ratcliffe H BItton A Building a thriving PHC system: the story of Costa Rica. Ariadne Labs, Boston2017Google Scholar
In other cases, the change was driven by political leaders seeking to serve the interests of specific constituencies and expand their legitimacy and influence. For example, in China, political leaders initiated equity-oriented health financing reforms as a means to meet ambitious development goals. Similarly in Ethiopia, the federal government's development policies emphasised poverty reduction and support for community-based initiatives in the health, education, and agriculture sectors. This was enabled through a significant public investment in a comprehensive PHC platform organised around a new cadre of health extension workers233WHOPHC systems ( PRIMASYS): case study from Ethiopia. WHO, Geneva2017Google Scholar and the Health Development Army of community volunteers. The health extension workers served as a focal point for expanded investments in health on the part of the government and its development partners, which are supported by the volunteers and local governance structures. The concept was rooted in the ruling party's political strategy of prioritising rural interests and seeking to unite ethnically diverse constituencies. This rural-focused strategy had previously enabled the party to govern territory successfully when operating as an insurgency,108Croke K The origins of Ethiopia's PHC expansion: the politics of state building and health system strengthening.Health Pol Plan. 2020; 35: 131-227Google Scholar and was rooted in its Maoist and Marxist political ideologies.
Technocratic elites ( actors who have both technical expertise and political leverage) and professional organisations, accompanied by effective bureaucracies with the ability and interest to operationalise reforms, can also initiate and drive change.
Early involvement of actors from several sectors, including leaders, technical experts, and social activists from inside and outside the health system, has proven instrumental in transforming PHC financing in many countries. Enhancing health sector governance is an essential first step. Particularly critical is attracting a broad range of actors in support of PHC financing reforms to augment the pool of technical knowledge and skills that can support system functioning and transformation, and to foster unity among diverse interest groups. For example, as shown in the Ghana case study ( presented in section 5), the introduction of capitation as the method of provider payment needed concurrence among the Ministry of Finance, medical professionals ' associations, and patients.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Getting their buy-in requires considering the economic interests of different actors. Therefore, managing up and building coalitions with the ministry of finance and other agencies as key partners, as well as addressing opposition, are essential when planning and implementing, for example, the introduction of capitation-based payment systems.
There are five key considerations related to bringing together the necessary mix of actors.
•Political will and legitimacy of the actors driving change are essential preconditions to generating a political process that enables collaborative policy making in support of effective policy. Ideally, this is combined with strong technical leadership at national and subnational levels of the health system. The leaders, benefiting from broad political support, and networks are key,2Balabanova D Mills A Conteh L et al.Good Health at low cost 25 years on: lessons for the future of health systems strengthening.Lancet. 2013; 381: 2118-2133Google Scholar and they do not need to be exclusively from the health sector. In Sierra Leone, for example, the removal of user fees in 2010 was actively led by the President Koroma, and supported by a wide range of actors, including the ministries of health and finance, donors, and civil society.234Witter S Brikci N Harris T et al.The free healthcare initiative in Sierra Leone: evaluating a health system reform, 2010-2015.Int J Health Plann Manage. 2018; 33: 434-448Google Scholar•Policy development requires the engagement of an enthusiastic group of pioneers or policy entrepreneurs to provide both technical expertise and the vision for the reform. The central role of policy entrepreneurs or political champions in taking forward major policy initiatives such as UHC was also documented in Nigeria.235Onoka CA Hanson K Hanefeld J Towards universal coverage: a policy analysis of the development of the National Health Insurance Scheme in Nigeria.Health Policy and Planning. 2014; 30: 1105-1117Google Scholar Similarly, health financing reforms started in Estonia in the late 1980s when more opportunities for local decision-making started to arise within the Soviet Union.182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar After the political transition, leaders from the University of Tartu, supported by external actors, drove the new vision of how PHC family practices should operate. The Ministry of Health funded early pilots before health financing transformations were initiated; the Ministry of Social Affairs and the Estonian Health Insurance Fund were also important supporters.182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar Key individuals provided a strong vision and stewarded diverse reform processes, while enlisting a critical mass of professionals ( namely, health-care providers and administrators interested in developing a sustainable financing system that would guarantee stable, earmarked funding for health) to provide support throughout the design and implementation of the reforms.236Atun RA Menabde N Saluvere K Jesse M Habicht J Introducing a complex health innovation, primary health care reforms in Estonia ( multimethods evaluation).Health Policy. 2006; 79: 79-91Google Scholar•Political leaders and policy pioneers alike need to be supported by effective bureaucracies. Several countries that have achieved good health at low cost through investments in, and transformation of, PHC have bureaucracies characterised by strong managerial and implementation capacity, institutional memory, and openness to change. In both Thailand237Patcharanarumol W Tangcharoensathien V Limwattananon S et al.Why and how did Thailand achieve Good health at low cost?.in: Balabanova D Ma MA Good health at low cost ' 25 years on What makes a successful health system? London School of Hygiene & Tropical Medicines, London2011Google Scholar ( Thailand's building of multi-actor coalition supporting PHC is outlined in the appendix [ p 43 ]) and Estonia,182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar bureaucratic elites and technocrats who could draw on their personal legitimacy provided both technical and political support, working with political actors and external experts to enable complex financing reforms. Conversely, in China, PHC financing reforms have been hindered by bureaucratic fragmentation, with local bureaucracies insufficiently incentivised and invested in developing solutions to the fundamental problems hampering PHC and with preference to invest in hospitals that attract political capital locally.145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar•Strong civil society engagement is frequently catalytic in generating and sustaining broad-based political platforms that build support for and sustain momentum towards PHC financing reform. Civil society movements, including workers ' unions and employers ' associations, have led to the right to health ( and in particular PHC) being enshrined in the constitutions of many Latin American countries ( as previously highlighted in Brazil and Costa Rica). In Thailand, civil society advocacy was an important factor in creating structures at both national and community levels. In South Africa, civil society organisations such as the Treatment Action Campaign were crucial in bringing about the introduction of antiretroviral therapy.238Heywood M South Africa's treatment action campaign: combining law and social mobilization to realize the right to health.J Hum Rights Prac. 2009; 1: 14-36Google Scholar•Creating and sustaining structures and institutions that promote and support collaboration and dialogue was important in Thailand, Kyrgyzstan, Turkey, and other countries. Engaging key actors effectively in efforts to improve PHC financing functions entails aligning their interests and clearly defining their roles. In practice, the coordination function is often taken on by a dedicated transformation team. Although this team might have access to key political players, it also needs to be sufficiently independent to provide impartial advice and guidance and to weather shifts in power. For example, Thailand and Kyrgyzstan created research units within their Ministries of Health that were instrumental in guiding policy towards the achievement of UHC and sustaining an orientation towards equity.2Balabanova D Mills A Conteh L et al.Good Health at low cost 25 years on: lessons for the future of health systems strengthening.Lancet. 2013; 381: 2118-2133Google Scholar In Turkey, Minister of Health Akdag created a reform team that oversaw the implementation of the Health System Transformation Plan. Similarly, in Rwanda dedicated institutions directly supported decision making and coordinated national programme implementation related to PHC financing, including at the National University of Rwanda, School of Public Health and the Rwanda Biomedical Centre, Kigali, Rwanda.239WHOPrimary health carePHC systems ( PRIMASYS): case study from Rwanda, abridged version. WHO, Geneva2017Google Scholar Such structures have been instrumental in generating evidence for financing reforms while maintaining independence from political processes.
Finally, collaboration is at the heart of the concept of a whole-of-government approach that transcends line ministries and other agencies ' typical portfolio boundaries to achieve shared multisectoral goals.240WHOResolution WHA A68/17: Contributing to social and economic development: sustainable action across sectors to improve health and health equity. WHO, Geneva2015Google Scholar This is particularly crucial to PHC and its financing, in which engaging the whole government involves, in part, recognising the relative power of different ministries involved ( particularly health, finance, and other social sectors such as education or water and sanitation), and ensuring that their interests align. In LMICs, the range of key stakeholders involved in designing and implementing PHC policies and programmes can be even broader, including key civil service agencies, donors, professionals, user associations, and civil society organisations—often disrupting the opportunities for joint action. This is particularly evident in areas such as the essential public health functions, a key component of PHC, under the remit of multiple sectors. Importantly, these intersectoral approaches and linkages need to underpin not only national strategic policies but be translated into structures and operational models at subnational levels such as district and local.
In Brazil, the municipalities are a key focal point in planning and implementing community-led multisectoral actions in response to local health needs and are governed by stakeholder committees.241Guerra E Citizenship knows no age: children's participation in the governance and municipal budget of Barra Mansa, Brazil.Environ Urban. 2002; 14: 2Google Scholar At the local level, the increasing importance of community health workers and multipurpose volunteers, whose role often incorporates tasks to promote social development and address social determinants of health which are core to PHC, and their linking in or integration within the health systems has meant that funding can be channelled more effectively to delivery of essential services ( see sections 1 and 5). For example, in Ethiopia, this is seen in the collaborative community-based multisectoral models involving health extension workers, facility-based PHC providers, community governance structures, and volunteers working in close coordination to improve health and wellbeing of the population. This is underpinned by a national strategy for PHC and the Health Sector Development Program acting as a blueprint for how different actors should link to each other.
However, coordination among ministries alone is insufficient for effective PHC financing policy and strategic investment—it also requires coherence across policies. This can be achieved by having an overarching vision for PHC, including strategies for improving routine operation and enabling reform. Despite general recognition that comprehensive PHC requires multisectoral action, in practice coordinating financing across sectors and at different levels of government is relatively uncommon. One exception is China, where a cross-ministerial health system reform administrative mechanism has shown promise, with local actors ( such as local vice governors and mayors responsible for PHC at the local level of government and the local health commissions) contributing to the ongoing development of integrated policies.145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar In Brazil, participatory management councils at the municipal level were even enshrined in the country's constitution, enabling them to manage powerful local interests.241Guerra E Citizenship knows no age: children's participation in the governance and municipal budget of Barra Mansa, Brazil.Environ Urban. 2002; 14: 2Google Scholar
PHC financing is subject to contestation that is dynamically changing over time. Policies promoted by one political coalition can be reversed when a new party comes to power. However, PHC financing is also path dependent, so initial decisions can determine the range of options that are available later. The importance of historical roots in fostering PHC that is people centred is seen in the UK's experience, where small general PHC practices funded by voluntary insurance were integrated into a national health system but preserved their autonomy.242Light DW Universal health care: lessons from the British experience.Am J Public Health. 2003; 93: 25-30Google Scholar In many LMICs, colonial histories have had a major role in defining how health financing systems are organised. For example, Algeria and Morocco both have social insurance schemes that are similar to the Bismarck model, and the French system. Egypt, meanwhile, has a social assistance scheme inspired by the English Poor Law. Gaza uses an Egyptian insurance scheme, stemming from Egypt's occupation of Gaza through 1967.243Loewe M Jawad R Introducing social protection in the Middle East and North Africa: prospects for a new social contract?.Int Soc Secur Rev. 2018; 71: 3-18Google Scholar The structure of the health system and payment for this system remains based on the legacy of the colonisers.243Loewe M Jawad R Introducing social protection in the Middle East and North Africa: prospects for a new social contract?.Int Soc Secur Rev. 2018; 71: 3-18Google Scholar
Although path dependency can mean that changes in PHC financing occur over a long period of time, with a series of reform steps building on each other, in some situations the direction of reform has changed at important junctures through radical socio-political or other crises, as in China ( how path dependency has influenced China's PHC financing is outlined in the appendix [ p 43 ]). Similarly, countries in Eastern Europe and the former Soviet Union had opportunities to rapidly overhaul resource mobilisation and purchasing arrangements for PHC after the political transition of 1989 and the collapse of the Union of Soviet Socialist Republics ( political transition as an important juncture for PHC financing transformation in the Eastern European region is outlined in the appendix [ p 44 ]). Although there is no doubt that compromise and aligning of actor interests and focusing on what is feasible are often required for changes to be politically viable, some of those compromises, although expedient, can greatly limit options later. Such limiting options for PHC financing include a focus on expanding population coverage by starting with formal sector employees, prioritising hospital services in the benefits package, and allowing for fee-for-service payments in the public sector.
Because of the dynamic nature of political processes, having a clear long-term vision, upheld and publicly stated over time, has been important in supporting the transformation of financing to enable PHC delivery models. Fostering effective financing functions and reform in line with this vision entails consistently engaging with politics and continually designing new technical solutions to emerging problems. In some cases, technical solutions can be developed while waiting for a window of opportunity to consider them to appear; in other cases such as Turkey's ( Turkey's political strategy to strengthen PHC and its financing is outlined in the appendix [ p 45 ]), rapidly changing political conditions create demand for novel technical solutions.
Once a clear vision has been agreed, moving towards PHC financing requires strategies for staying on course while retaining flexibility. Therefore, it involves maintaining direction of travel through periods of political stability and economic growth, taking advantage of windows of opportunity created by adverse political events and crises ( such as COVID-19), and persisting through periods of stagnation. The balance of power among different groups also evolves over time, leading to the emergence of new agendas, new actors, and new coalitions. Reformers who have candidate technical solutions can slowly gather support for reforms that are initially unpopular or require strategic compromise. The case of the Seguro Popular in Mexico, for example, highlights the importance of strategic compromise and targeted negotiation to move reform processes forward, from abandoning the idea of merging the Mexican Social Security Institute and other social security programmes into a single organisation, to allowing enrolment without premium payment for almost the whole population.225Sparkes SP Bump JB Özçelik EA Political economy analysis for health financing reform.Health Syst Reform. 2019; 5: 183-194Google Scholar Brazil, Ethiopia, and China offer examples of countries where comprehensive reforms have been implemented and refined over decades, maintaining a consistent direction while adapting to political and socioeconomic transitions and considerable uncertainty.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar, 118Woldie M Resource mobilisation and allocation for PHCPHC: lessons from the Ethiopian health system. London: Lancet Global Health commission on financing people-centred PHC.https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar, 145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar
Examining the early efforts of countries that have successfully implemented long-term PHC financing and delivery transformation reveals the importance of building strong foundations to support ongoing changes. These foundations can be technical ( ie, ensuring that the technical features of the reform were ready to be used at the earliest opportunity, as in Turkey), or can involve investing in PHC delivery capacity ahead of the reform, which helped Thailand, Ethiopia, and Estonia to absorb additional financial flows and enable large-scale shifts to PHC-focused health systems. In both cases, this involved creating new PHC cadres ( eg, health extension workers in Ethiopia and family practitioners in Estonia) that were deployed nationally, instituting training and supervision structures, and embedding best practice norms and clinical standards. In addition to training human resources and extending PHC infrastructure, these activities generated visibility for the early reforms that improved buy-in among different constituencies. Thailand developed standard designs for PHC infrastructure and built many facilities, making services widely accessible with over 10 000 PHC facilities—one per 6000 population—linked to strong community-based volunteer programmes and widespread public health interventions such as dengue control.244Blecher M Pillay A Patcharanarumol W et al.Health financing lessons from Thailand for South Africa on the path towards universal health coverage.S Afr Med J. 2016; 106: 4-5Google Scholar These reforms created public support for PHC and willingness to allocate new resources.
Finally, identifying strategic compromises has also characterised many countries ' efforts in financing PHC. For example, in Estonia, policy makers passed iterative step-wise health-care reforms from the early 1990s to the end of the 2000s, strengthening the PHC system. In the early stages they adopted an explicit tactic of lying low and not inviting publicity and identifying paths of least resistance for implementation until a critical mass of supportive PHC providers ( general practitioners) emerged.245WHOCountry case studies on primary health carePHC: Estonia: the development of family practice to support universal health coverage. World Health Organization, Geneva2018Google Scholar Compromise can be achieved through iterative processes of piloting, evaluating, and adapting PHC financing innovations before their scaling up—Rwanda, Burundi, and Burkina Faso all did this when introducing results-based financing.246Witter S Anderson I Annear P et al.What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies.Health Res Policy Syst. 2019; 17: 9Google Scholar In China, provincial-level pilot programmes were evaluated, results disseminated, and experiences shared.145Xu J Yuan B The progress and challenges in China's health financing development towards integrated people-centred health services—a systems perspective. Lancet Global Health commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar In Thailand, high-level bureaucrats started implementing reforms ( including payment reform) as part of a national pilot, and were able to refine the policies before they had to be approved by Parliament. In Brazil, reformers started implementing pilots of the proposed reforms in selected municipalities. These pilots were then enabled by the 1988 Constitution, which established a national health system for the entire country.245WHOCountry case studies on primary health carePHC: Estonia: the development of family practice to support universal health coverage. World Health Organization, Geneva2018Google Scholar
In addition to political conditions, inter-related social and economic factors can also support or hamper routine operation and reform of PHC financing ( figure 13).
A range of social conditions influence financing arrangements. These include: the degree of inequality in a society, the availability of health workers with the capacity to implement reforms, prominent social grievances that propel certain issues to centre stage, and the strength of the social contract between the state and the population, among others.
Inequalities within a nation or society can provoke dissent against the status quo and foster support for reforms aimed at redressing the problems. China's 2009 health reforms stemmed from widespread complaints from the population about severe inequality in access to health care, as out-of-pocket payments continued to cripple households financially, accounting for about 60% of total health expenditure.247Meng Q Mills A Wang L Han Q What can we learn from China's health system reform?.BMJ. 2019; 365l2349Google Scholar
Similarly, in Brazil, the thirst for greater equity among segments of the population and better representation after decades of dictatorship propelled successful adoption of broad health system reforms based on principles of health care as a citizen's right and a government responsibility. This formed the basis for a universal, comprehensive, and decentralised health system open to both community participation and, to some extent, private sector initiatives.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar
Social grievances against the state or government bodies could also influence the success of a financing reform. Turkey tried to roll out a Family Doctors Programme, which included a swathe of financing and other health reforms, after unpopular decentralisation and privatisation policies had been implemented in the health sector. Those processes had created significant dissatisfaction amongst the population, as well as medical associations and physicians. The Family Doctors Programme was perceived as a similar strategy and met resistance.248Espinosa-González AB Normand C Challenges in the implementation of PHC reforms: a qualitative analysis of stakeholders ' views in Turkey.BMJ Open. 2019; 9e027492Google Scholar In Nigeria, a distrust of the national government led to the resistance of civil servants at the subnational level towards making contributions to the national health insurance scheme that would guarantee access to PHC, prevented the adoption of the scheme by subnational governments, delayed coverage expansion, and left the scheme as a voluntary programme.249Onoka CA Onwujekwe OE Uzochukwu BS Ezumah NN Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria.Health Res Policy Syst. 2013; 11: 20Google Scholar
The strength of the social contract between the population and the state can affect how reforms are received. In the state of Kerala, India, for example, the strong social contract between the state leadership and the population has been partly credited for its early successes in tackling the COVID-19 pandemic.250Chathukulam J Tharamangalam J The Kerala model in the time of COVID19: rethinking state, society, and democracy.World Dev. 2021; 137105207Google Scholar In the Middle East and North Africa, political regimes that came to power after independence also established social contracts that included providing material benefits, such as expanded access to primary and secondary health care.243Loewe M Jawad R Introducing social protection in the Middle East and North Africa: prospects for a new social contract?.Int Soc Secur Rev. 2018; 71: 3-18Google Scholar The weakening of these social contracts over time has driven widespread resistance to more recent reforms, and contributed to the 2011 uprisings across the region.
The existence of certain capacities ( in the society at large and the health sector in particular) is also important when promoting change. Any health financing reform, such as the introduction of a new budgeting approach or a new provider payment structure, requires skilled staff to communicate and manage the transition and to implement the new approaches. As mentioned in section 3, having insufficient technical budgeting capacity at the Ministry of Health, for example, weakens its bargaining position during national budgeting cycles. This was the case in India, where the scarcity of capacity of the states to prepare health budgets and plans aligned with the central government's expectations has weakened their ability to obtain resources for PHC.126Gertler PJ Giovagnoli PI Martinez S Rewarding provider performance to enable a healthy start to life: evidence from Argentina's Plan Nacer. World Bank Policy Research Working Paper. The World Bank, Washington DC, WA2014Google Scholar
Importantly, crises of any type can be transformed into opportunities for PHC reform if reformers are poised to act. In the UK for example, the National Health Service was created following the hardship of World War 2.251The National ArchivesOriginis of the NHS.https: //www.nationalarchives.gov.uk/cabinetpapers/alevelstudies/origins-nhs.htmDate: 2021Date accessed: September 3, 2021Google Scholar In Costa Rica, a 1991 measles outbreak led to employers across the country being forced to pay for private care for their workers due to weak public PHC.252Pesec M VanderZanden A Ratcliffe H Integrated people-centred health services case study: comprehensive PHC reform in Costa Rica.https: //www.integratedcare4people.org/media/files/Comprehensive Primary Health Care Reform in Costa Rica January2020 .pdfDate: 2020Date accessed: September 1, 2021Google Scholar Employers then threatened to stop making their social security contributions, contributing to government investment in a comprehensive PHC system. The Chinese health reform of the early 2000s, which involved substantial investments in PHC, was triggered in part by the 2003 SARS epidemic.253Yu H Universal health insurance coverage for 1·3 billion people: What accounts for China's success?.Health Policy. 2015; 119: 1145-1152Google Scholar
The COVID-19 pandemic has been a particularly severe global shock that has affected societies and economic outlook, as discussed throughout the report. The political economy of the pandemic itself, and the response to its devastating consequences, has also started to be scrutinised, and will require further exploration.254Bump JB Baum F Sakornsin M Yates R Hofman K Political economy of covid-19: Extractive, regressive, competitive.BMJ. 2021; 372: 372-373Google Scholar For now, it has triggered initiatives and debates on how PHC needs to be transformed to cater for changing needs.255Rifkin SB Fort M Patcharanarumol W Tangcharoensathien V Primary healthcare in the time of COVID-19: breaking the silos of healthcare provision.BMJ Glob Health. 2021; 6e007721Google Scholar
National and global economic conditions have significant influence on health financing. These conditions include the structure of the economy, economic cycles of stagnation, recession, or growth, the structure of the health care provider market, the size and dynamics of the private sector, and the importance of aid as a source of financing for health.
As discussed in section 3, the structure of a country's economy has a substantial impact on financing for PHC. In low-income countries, only a small portion of the population and private sector organisations are subject to taxes. In Tanzania, for example, just 286 organisations contribute 70% of domestic tax revenue.98Mills L Barriers to increasing tax revenue in developing countries. Institute of Development Studies, Brighton2017Google Scholar Those who do pay taxes in countries with small tax bases have substantial power in driving what reforms can be implemented. The level of informality in the labour market dictates whether any type of labour employment tax or health insurance contributions will generate sufficient revenue to support social health insurance. In Ethiopia, for example, attempts to implement social health insurance have stalled for many years in part due to the high level of labour informality.
In addition to the structure of a country's economy, where the country is in the economic cycles of growth and contraction can influence the success of a reform aimed at increasing financing for PHC. In Brazil, the fiscal space generated from sustained economic growth during the 2000s enabled the country to increase its public health expenditures.107Massuda A Malik AM Lotta G Siqiueira Tasca R Rocha R Brazil's PHC financing: case study. Lancet Global Health Commission on financing people-centred PHC, London2021 ( available at https: //www.lshtm.ac.uk/financing-phcDate accessed: December 6, 2021Google Scholar In Chile, similarly, important PHC reforms were made possible by high economic growth during the first decades of the country's return to democracy.55Cuadrado C Fuentes-Garcia A Barros X Martinez MS Pacheco J Financing primary health care in Chile. Lancet Global Health Commission on Financing People-Centred Primary Health Care, London2021https: //www.lshtm.ac.uk/financing-phcDate accessed: July 19, 2021Google Scholar However, in Finland, the collapse of trade with the former Union of Soviet Socialist Republics in 1992 led to a steep economic decline and, as a result, national expenditure on health care was slashed by 12% in 1991–94.256Keskimäki I Development of primary health care PHC in Finland. Lancet Global Health Commission on financing people-centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar
The structure of the health-care provider market also influences reforms, particularly those to do with purchasing. On the one hand, in Estonia, the Association of Family Doctors had a major role as a partner to the national insurance agency in designing and implementing laws to support PHC financing.182Kasekamp K Habicht T The milestones of reforming PHC in Estonia. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar In Ghana, on the other hand, the design and implementation of the national health insurance scheme was influenced by the strong bargaining power of providers, who preferred being paid on a fee-for-service basis and resisted a system change that would affect payment mechanisms for PHC.257Otoo N Awittor E Marquez P Saleh K Universal Health Coverage for Inclusive and Sustainable Development: country summary report for Ghana. World Bank Group, Washington, DC2014Google Scholar
Finally, the size and dynamic nature of the private sector is another critical economic factor that can influence health financing reform efforts. In Thailand, for example, the capitation system was designed to improve quality of care through fostering competition among PHC providers. This was possible in Bangkok, where a large number of private providers were willing to accept patients with insurance ( as the capitation system was part of the national health insurance scheme).184Mills A Bennett S Siriwanarangsun P Tangcharoensathien V The response of providers to capitation payment: a case-study from Thailand.Health Policy. 2000; 51: 163-180Google Scholar In Ghana, on the other hand, the shortage of public and private providers in rural areas constrained competition during the capitation pilot in Ashanti region.189Amporfu E Ghana's experience changing provider payment to capitation in PHC. Lancet Global Health Commission on Financing People-Centred PHC, London2021https: //www.lshtm.ac.uk/financing-phcPHCDate accessed: December 6, 2021Google Scholar
As noted, political economy analysis seeks not only to explain but also to derive practical implications for strategic policy making. It explains how the political and socioeconomic contexts shape what is possible or not in developing and implementing key policies. Although some cross-country lessons can be drawn ( with caution) from the country examples discussed throughout this report, the critical influence on PHC financing functions of the political, social and economic conditions that make up the political economy are best understood within each national, and often subnational, context. Analysis of these factors should be an integral ongoing part of implementing feasible interventions to improve efficiency and equity of PHC financing. A common thread is that there is no blueprint approach to changing PHC financing, and even within a country, the political economy context also changes over time, often rapidly.
Political economy analysis can be used to inform proactive or responsive strategies for adaptive management of the interests of different actors and formulating strategies that fit the social and economic conditions in support of health financing reforms. A political economy lens focuses on understanding the structural and socioeconomic conditions underpinning decision making and conflicting interests. This understanding might lead to, for example, the use of strategies to strengthen actors with limited power but who would benefit most from more effective PHC financing. In other cases, political economy analysis may indicate the need to anticipate and manage resistance from those who benefit from the status quo, and to identify opportunities to form coalitions. Practical approaches to using political economy analysis to underpin routine operation or transformation of PHC financing are outlined in the appendix ( p 45).
Designing politically informed technical strategies starts by asking the right questions to navigate the complex political economy context ( Sparkes S, WHO, personal communication).258Barnett A Stockbridge M KIngsmill W Political economy of Africa's power sector. Policy Practice Brief 10, 2016.https: //www.thepolicypractice.com/sites/default/files/202020020-0-5/pb10pe africa power sector.pdfDate accessed: July 21, 2021Google Scholar In this Commission, we have formulated a series of key questions that should be asked throughout the policy cycle, and can be used for setting the agenda as well as designing and implementing people centred PHC financing policies: •What is the problem to be addressed? What ideas exist for improving PHC financing? What technical strategies would achieve this over time? •Who are the stakeholders with an influence over the problem? What are their positions on the topic, and what is their relative power? •What are the political dynamics at play? •What could help to shift incentives to promote the changes pursued? •What social and economic conditions that underpin the political process could present opportunities or constraints for the proposed change? •What are the most likely pathways for change? What are possible entry points to move the reform forwards? If there is a potential window of opportunity, how can it be used to generate and sustain political momentum? •How do the proposed strategies take into account path dependency? •How should the strategies be sequenced?
Although awareness of and the need to conduct political economy analysis is a part of developing policies for sustainable and equitable PHC financing, country-level capacity to do so can be scarce. Investing in basic supportive functions, which include technical capacity to do political economy analysis, ability to engage with actors and policy processes, and translate knowledge to policy is key. Importantly, there is often knowledge of political economy analysis developed in other sectors that can be used in policy development in the health sector. Support for, and retention of professionals who can develop and integrate specific aspects of political economy analysis in their work should be ongoing. Subnational entities such as districts can be incentivised to co-fund training and recruitment of managerial or research cadre able to use particular political economy analysis skills, relevant to context, as a part of leadership programmes. We argue that sustaining political economy analysis is key as a part of investment in both system transformation and strengthening routine financing systems; it is particularly important in effectively responding to large-scale shocks such as pandemics or political transitions.
Technical strategies for efficient and equitable financing for PHC are neither designed nor implemented in a vacuum. They are critically shaped by political, economic, and social conditions—and the dynamic nature of these forces can create opportunities to maximise impact, or impose barriers that constrain success. Applying a political economy lens to technical solutions that explicitly recognises the evolving roles of actors beyond the health system, their relative resources and power, as well as the economic constraints and social relations, is therefore necessary to strengthen the PHC financing architecture.
The Commission's deliberations have analysed how health financing arrangements can be used to drive national health systems to provide equitable, comprehensive, integrated, and high-quality PHC, delivered through platforms that are responsive to the needs of the populations they serve, and fully aligned with the objectives of UHC.
We argue that countries should invest more and invest better in PHC, and that the financing arrangements that support PHC—from mobilisation and pooling of resources, to budgeting, allocation, and purchasing—must place people at the centre. They must also be driven by a focus on equity and social justice, in line with the original Alma Ata vision. We articulate the features of people-centred financing for PHC below. We recognise that the opportunities to reorient health financing policies towards PHC depend on the economic, social and political features of a particular regional, national, or sub-national context, and that there is no single pathway to achieving optimal PHC financing ( figure 14).Figure 14Framework for people-centred financing of PHCView Large Image Figure ViewerDownload Hi-res image Download ( PPT)
An overarching position of the Commission has been the principle of progressive universalism: This means that governments should prioritise equity by providing universal access to affordable, quality PHC services, and particularly on ensuring that disadvantaged groups are reached first. Guaranteed entitlements can expand beyond PHC as fiscal capacity increases.
Beyond this overarching principle, the Commission has identified four key attributes of people centred financing for PHC.
First, public resources should provide the core of PHC funding with minimal reliance on direct payments when services are accessed. In most LMICs, this level of public funding can only be generated through increasing allocations to PHC from general tax revenue. Revenue raising mechanisms should be defined based on ability to pay and be progressive. While each country is at a different starting point for a shift to predominantly public funding, strategic and purposeful change to national health financing systems over time can enable gradual progress. In the meantime, low-income countries will require continued development assistance to secure a sufficient resource envelope to enable population coverage of essential PHC services.
Second, pooling arrangements should cover PHC. By supporting PHC with pooled public funds, out-of-pocket payments can be reduced to levels at which they do not pose financial barriers to accessing needed care, impoverish households, or push households deeper into poverty. Pooling enables cross-subsidy among those who are well and those who are ill, and among the poor and the wealthy.
Third, resources should be allocated equitably across levels of service delivery and geographic areas, and be protected to reach frontline PHC service providers and patients. Resource requirements for PHC should be estimated on the basis of accurate assessments of population health needs. Countries should deploy strategic resource allocation tools ( including needs-based per-capita resource allocation formulae) in budget formulation, budget execution, public financial management policies, and service delivery arrangements to channel and protect the flow of resources for PHC.
Fourth, provider payment mechanisms should: assign resources based on people's health needs; create the right incentive environment to promote PHC that is people-centred along the spectrum of prevention, health promotion, and treatment; foster continuity and quality of care; and be flexible enough to respond to changing needs of patients, families and communities. This is best achieved through a blended provider payment system with capitation at its core.
Table 2 presents a matrix which maps how financing arrangements can be deployed to achieve the dual goals of people-centredness and equity.Table 2The Commission's vision of financing functions and arrangements for PHC that is people centred and equity drivenMobilisationPoolingAllocationPurchasingPeople-centred characteristicsResource requirements for PHC should be estimated based on what is needed for each person to access; PHC that is people centred as defined in the country's contextEveryone is included in the poolResources are allocated based on population needs for PHC that is people centred ( rather than on facilities, inputs, or vertical programmes) Purchasing arrangements and provider payment mechanisms are linked to making PHC that is people centred available to people and flexible enough to accommodate different modes of delivery; funds flow to and are managed by frontline providers as defined in the country contextEquity and progressive universalism characteristicsRevenue-raising mechanism is defined based on ability to pay and is progressiveCross-subsidisation occurs between poor and wealthy populations and healthy and sick populations; use of pooled funds prioritises making PHC accessible, with financial protection and subsidies directed to the poorThe mechanism used to allocate public funds prioritises the needs of the poorest segments of population, and areas ( geographical or health) of greatest needPer capita payment ( capitation) is the starting point, which makes the same amount of funds available to providers to deliver the PHC package for each person ( adjusted upward or downward according to health needs) Practical implications and anticipated outcomesReduces out-of-pocket expenditure; progressive taxation policiesMerge or consolidate existing pools into larger pools ( including formal and informal sectors, poor and rich; coverage dominated by public financing); who and what are covered by the pool expands in the most equitable and PHC-centric way; progressively move to universal health coverage according to the macro-fiscal capacity of the country, starting with access to PHC for all and financial subsidies directed to the poorest and most vulnerable; access to more services beyond PHC and subsidies for more population groups can expand as macro-fiscal capacity expandsBudgeting is based on needs-based per capita allocations to enable access to PHC that is people centred ( rather than to facilities, inputs, or vertical programmes); protect resources going to PHC through existing policy tools, such as programme budgets, resource allocation formulae, conditional grants or statutory rules; define a benefit package that prioritises coverage of the needs of poorest segments of population; ensure resources reach frontline providers ( through direct facility financing, for example) and improve public finance management systems more broadly; organise service delivery to pull resources to PHC, for example by creating new cadres of frontline PHC providers, defining explicit service standards, or instituting effective referral systemsEstablish a blended payment model with capitation at its core: start with a baseline capitation payment. The payment amount should be determined using a formula that links the payment parameters ( base per capita rate, number of enrolees linked to the provider, and any individual or provider-level adjustments) to a defined package of PHC services; define a PHC package; adjust the risk level to prioritise those in greatest needPHC=primary health care. Open table in a new tab
Together, these attributes form the foundations of a resilient and responsive health financing system. As has become evident during the COVID-19 pandemic, effectively financing PHC during a crisis period relies on the existence of a health system that is capable of surging to tackle new priorities while also continuing to deliver existing services. Resource mobilisation, pooling, allocation, and purchasing systems must be able to respond quickly to deliver additional resources while protecting allocations to PHC.
We acknowledge that there is no single pathway to achieve optimal PHC financing, and that every country is at a different point in orienting its PHC policies and financing. Moreover, it will take time to adapt financing arrangements, and these will need to continue to adapt to changing conditions and needs over time, and to respond to shocks. However, by moving deliberately towards publicly-financed, progressively universal, and population-based health financing, countries can support the expansion and improvement of PHC.
In support of this vision, the Commission makes five recommendations to local, national and global policy makers and other relevant stakeholders ( panel 20). We recognise that many of the recommendations could potentially be applicable to health system reform in general. However, we continue to focus specifically on PHC, while endeavouring to avoid separating it out from the rest of the health system.Panel 20Our vision for people-centred financing of primary health care ( PHC) PHC needs both more and better resources. The Commission's vision is of a people-centred system for financing PHC. This system should be capable of collecting, pooling, and allocating resources to purchase services that ensure that all people ( community members, patients, and providers) are able to benefit. Progressive universalism—ensuring that, at every step, people who are poor or vulnerable gain at least as much as those who are wealthy or privileged—is at the core of this vision. Achieving this vision requires: •An adequately-financed health sector, funded by expanded public and pooled sources, that protects everyone from financial hardship when seeking care. The Commission argues for an explicit focus on addressing inequities first. This entails that revenue will be raised based on ability to pay and through progressive means.•Pooled funding will cover PHC, to enable everyone to receive PHC that is free at the point of use. Pooling of resources will support cross-subsidisation among those are well and those who are ill, and among the poor and the wealthy.•A strategic use of all available policy tools to direct sufficient resources to PHC to enable a universally-accessible system that provides high-quality services according to a defined benefit package appropriate to the level of care and aligned with macro-fiscal capacity. In line with our core focus on people-centeredness and equity, the Commission proposes that resources are allocated based on population needs, prioritising the needs of the poorest segments of the population. To do so will require mechanisms for funding, budgeting, and financial management that ensure that resources reach frontline providers and platforms.•A context-specific blended payment model built on capitation. Payment systems should allow adequate resources to flow to the PHC level in ways that: are equitable; match resources to population health needs; create the right incentive environment to promote the full PHC spectrum of prevention, health promotion, and management and treatment; foster people-centeredness, continuity, and quality of PHC; and, are flexible enough to support changes in service delivery models and approaches.•A nuanced understanding of the political economy of each country throughout the development and implementation of all policy to accompany the technical approaches to ensuring people-centred financing for PHC.
PHC needs both more and better resources. The Commission's vision is of a people-centred system for financing PHC. This system should be capable of collecting, pooling, and allocating resources to purchase services that ensure that all people ( community members, patients, and providers) are able to benefit. Progressive universalism—ensuring that, at every step, people who are poor or vulnerable gain at least as much as those who are wealthy or privileged—is at the core of this vision. Achieving this vision requires: •An adequately-financed health sector, funded by expanded public and pooled sources, that protects everyone from financial hardship when seeking care. The Commission argues for an explicit focus on addressing inequities first. This entails that revenue will be raised based on ability to pay and through progressive means.•Pooled funding will cover PHC, to enable everyone to receive PHC that is free at the point of use. Pooling of resources will support cross-subsidisation among those are well and those who are ill, and among the poor and the wealthy.•A strategic use of all available policy tools to direct sufficient resources to PHC to enable a universally-accessible system that provides high-quality services according to a defined benefit package appropriate to the level of care and aligned with macro-fiscal capacity. In line with our core focus on people-centeredness and equity, the Commission proposes that resources are allocated based on population needs, prioritising the needs of the poorest segments of the population. To do so will require mechanisms for funding, budgeting, and financial management that ensure that resources reach frontline providers and platforms.•A context-specific blended payment model built on capitation. Payment systems should allow adequate resources to flow to the PHC level in ways that: are equitable; match resources to population health needs; create the right incentive environment to promote the full PHC spectrum of prevention, health promotion, and management and treatment; foster people-centeredness, continuity, and quality of PHC; and, are flexible enough to support changes in service delivery models and approaches.•A nuanced understanding of the political economy of each country throughout the development and implementation of all policy to accompany the technical approaches to ensuring people-centred financing for PHC.
Establish financing arrangements for PHC following a principle of progressive universalism and incorporating the people-centred attributes outlined above. These are: public resources provide the core of PHC funding; pooled funds should cover PHC; resources should be allocated equitably and protected so they reach front-line providers; and provider payment is through a blended mechanism with capitation at its core.
Key actors and stakeholders should be involved in designing and implementing people-centred PHC financing reforms. Although the specifics will vary depending on the national context, some general roles and responsibilities can be identified.
The ministry of health should lead efforts to prioritise PHC. Leadership involves promoting technical strategies embodying the above principles, ensuring that sufficient resources are made available, and elaborating and pursuing political strategies in support of expanding and improving PHC financing. The ministry of health should ensure it has the technical expertise to make the case for more funding for PHC. To ensure accountability, which sections within the ministry of health are responsible for the financing and delivery of PHC should be clarified. The ministry should take responsibility for engaging the commitment of the other sectors ( such as education and water and sanitation) whose activities relate to PHC.
The ministry of finance should enable the mobilisation of sufficient revenue to adequately finance people-centred PHC, as defined nationally. The ministry of finance should work with the ministry of health and other agencies to develop flexible and responsive public finance management systems that make allocations to PHC visible, protect resource flows to reach the frontlines, and allow strategic provider payment systems that evolve as capacity grows and service delivery models mature.
Local government agencies should serve as bridges between local populations and central government ministries. Local authorities are well-positioned to identify and communicate populations ' needs so they can be accurately captured in allocation formulas. Local agencies are also responsible for integrating multiple funding flows and ensuring they are applied to addressing local priorities.
Communities and civil society groups should demand changes. Communities should engage in efforts to hold PHC providers accountable, and be included as partners in monitoring progress. To that end, a key priority for civil society groups should be building the capacity of communities to undertake these functions. Governments should facilitate this accountability by producing data to enable monitoring.
Health-care providers and their representative organisations should actively participate in efforts to reform PHC financing arrangements. Providers must engage in the design of payment reforms, understand the implications of proposed changes to provider payment systems, and take any and all opportunities to provide people-centred health care fostered by reformed financing arrangements.
Donor and technical agencies should provide financial resources and expert technical support to countries that need assistance to jumpstart changes in PHC financing. At country level, agencies should ensure that, at the very least, their actions do no harm. Agencies should immediately change their approaches to providing financial and technical assistance to reduce fragmentation. At best, donor and technical support agencies can be strategic partners to the national governments working to improve their financing systems to support PHC that is people centred.
Each country should articulate a vision for financing PHC. Having a clear vision allows decision makers to plot a strategic technical path and identify what political engagement is needed from stakeholders throughout the system to support progress.
National funding champions of PHC should proactively explore and recognise the political, economic, and social conditions at subnational, national, and global levels to effectively navigate towards the vision through the evolving political economy context. This political economy analysis should begin at the outset of any reform process.
Implementing politically-informed technical strategies ( ie, strategies rooted in a thorough understanding of the political economy context within which the technical approach sits) should involve regular mapping of the political landscape, assessing opportunities to align interests and build coalitions among actors from different sectors and administrative domains, and communicating and working towards collaboration and strategic compromises in support of key technical policies. This might require strengthening the skills of people working in government, and in academic and donor partners, to undertake political economy analysis.
The country's vision should be operationalised by mapping out a clear set of steps to pursue its chosen course, while also preparing to capitalise on unexpected opportunities and creating room to manoeuvre as needed to adapt to political and socioeconomic changes, crises, and other shocks.
All stakeholders should undertake ongoing efforts to strengthen the health system's basic functions, including data collection and analysis of resource flows and health impacts; monitoring, evaluation, and learning systems; public finance management systems that enable resources to reach frontline providers; and capacity of providers to manage funds effectively. Investment in such basic functions is needed in conjunction with investment in PHC.
A new reporting item ( ie, memorandum item) on PHC should be defined and included in countries ' annual reporting of health expenditures to WHO for the Global Health Expenditure Database.
In the meantime, current reporting should be adapted to be based on a cross-classification of functions and providers ( such as the one used by the OECD). This will provide more specific and useful data by, for example, allowing for differentiation between hospital and ambulatory providers, and enable an operational definition of PHC based on service delivery platforms.
The categories currently included in the calculation of PHC expenditure should be revised. In particular, how administrative costs are included and how outpatient services in hospitals are classified should be reconsidered, as current practices skew estimates of PHC spending upwards.
Most importantly, each country should establish a clear definition of PHC expenditure that is compatible with how its health system organises services; it can then use this definition to track spending over time to monitor progress.
The Commission recognises that its work represents the beginning, not the end, of a research agenda on financing people-centred PHC. The Commission's explorations raise many additional questions, starting with those presented in panel 21. The Commission proposes the following next steps and starting points for additional exploration by key stakeholders, including academic researchers, technical experts, policy makers, donors, and others: •Creating a tool for national mapping of PHC financing ecosystems to create a firm data foundation for developing appropriate technical and political strategies to advance people-centred financing in support of PHC. Collaboration among researchers, technical experts, and policy makers is needed to develop a robust tool and method.•Exploring and devising innovations to support better PHC financing, including adopting implementation science and other operational research methods.•Securing funding from governments and other donors for rigorous research on the research questions suggested in panel 21, as well as others that will arise.Panel 21Research questions on financing for primary health care ( PHC) that is people centredThe Commission's work has answered some questions, particularly on technical aspects of financing arrangements. But it has raised many others, most especially on how to operationalise our recommendations. These are the ‘ how do we do this?’ questions. Going forward, the research agenda on financing PHC should study the outcomes of proposed reforms and examine implementation at country and local level. Key topics and questions include: Innovative approaches to support the delivery of PHC: •What are the best ways to channel funds directly to facilities? •What are the effects on health outcomes of getting money to frontline providers? •How can digital innovations be used in health financing systems, while promoting universal health coverage and minimising fragmentation? Spending more and spending better on health in general and PHC in particular: •What bottlenecks in health financing reforms arise in particular settings? What are the best approaches to counteracting them? •What strategies that have been effective in ensuring financing for essential public health functions and linking them to PHC can be replicated, and how? •What methods and data work well in measuring implementation of health financing reforms and tracking how funding flows change ( including volume, recipients, timeliness, and equity)? How can these methods be used at the local, national, and global levels? •Why are reforms addressing even well-known financing inefficiencies difficult to implement, and how can the reforms addressing these inefficiencies translate into additional financial resources for PHC? •How can researchers collaborate effectively with policymakers to evaluate potential solutions and respond to their priorities and concerns? The political economy factors of financing PHC: •What strategies have been used to effectively manage political economy considerations of providers and patients in health reforms? What are patients ' and providers ' understandings and attitudes towards proposed financing reforms? •How can local actors be supported to foster investment and allocation in PHC? What power shifts are needed and which technical capabilities are most relevant? •How do local and central government bodies interact in designing and implementing health financing reforms? What political economy considerations are important when seeking to influence resource allocation in decentralised settings? •What are the political economy considerations for efforts in LMICs that seek to address fragmentation in pooling and shifting provider payment mechanisms towards capitation? What approaches can be effectively used to manage these factors?
The Commission's work has answered some questions, particularly on technical aspects of financing arrangements. But it has raised many others, most especially on how to operationalise our recommendations. These are the ‘ how do we do this?’ questions. Going forward, the research agenda on financing PHC should study the outcomes of proposed reforms and examine implementation at country and local level. Key topics and questions include: Innovative approaches to support the delivery of PHC: •What are the best ways to channel funds directly to facilities? •What are the effects on health outcomes of getting money to frontline providers? •How can digital innovations be used in health financing systems, while promoting universal health coverage and minimising fragmentation? Spending more and spending better on health in general and PHC in particular: •What bottlenecks in health financing reforms arise in particular settings? What are the best approaches to counteracting them? •What strategies that have been effective in ensuring financing for essential public health functions and linking them to PHC can be replicated, and how? •What methods and data work well in measuring implementation of health financing reforms and tracking how funding flows change ( including volume, recipients, timeliness, and equity)? How can these methods be used at the local, national, and global levels? •Why are reforms addressing even well-known financing inefficiencies difficult to implement, and how can the reforms addressing these inefficiencies translate into additional financial resources for PHC? •How can researchers collaborate effectively with policymakers to evaluate potential solutions and respond to their priorities and concerns? The political economy factors of financing PHC: •What strategies have been used to effectively manage political economy considerations of providers and patients in health reforms? What are patients ' and providers ' understandings and attitudes towards proposed financing reforms? •How can local actors be supported to foster investment and allocation in PHC? What power shifts are needed and which technical capabilities are most relevant? •How do local and central government bodies interact in designing and implementing health financing reforms? What political economy considerations are important when seeking to influence resource allocation in decentralised settings? •What are the political economy considerations for efforts in LMICs that seek to address fragmentation in pooling and shifting provider payment mechanisms towards capitation? What approaches can be effectively used to manage these factors?
In this report, we have set out a vision for placing people at the centre of the arrangements for financing PHC. This financing vision serves a greater ambition: health systems that provide equitable, comprehensive, integrated, and high-quality PHC delivered through platforms that are responsive to the needs of the populations they serve and fully aligned with the objectives of UHC.
The initial conceptual framework for the Commission was developed by KH together with DB and TP-J, and all authors collaborated in refining it. The first draft of the report was written by a core writing team led by KH and included NB, DE, TP-J, and DB. All authors contributed intellectual content to the report concepts, conclusions, and recommendations, and to the writing and editing of subsequent drafts. Support to case studies was provided by QM ( China), RS and AE ( India), JVM ( Chile) and EN ( New Zealand, Estonia, and Finland). The provider payment survey was designed by CK, TP-J and DE, with additional input from CC, MR and MdA, and data collection from their networks was facilitated by CK and CC. KH, TP-J, DB, DE and NB accessed and verified the underlying data. The opinions expressed in the publication are those of the authors and do not necessarily represent the views, decisions or policies of the funder or the institutions with which the Commissioners are affiliated. All authors had full access to the data in the study and accept responsibility for the decision to submit for publication.
KH, DB, NB, DE and TP-J were funded by a grant from the Bill & Melinda Gates Foundation. DH has received funding from the Bill & Melinda Gates Foundation for various activities at UNICEF, including on health system strengthening and community health, both of which are mentioned in this report. In the period during which the report was developed, AE and HWa were employed by the Bill & Melinda Gates Foundation and were involved in data analysis, interpretation and writing of the report. All other authors declared no conflict of interest.
This report is based on research funded by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation. Brazil case study was undertaken by Adriano Massuda, Ana Maria Malik, Gabriela Lotta, Marina Siqueira, Renato Tasca, Rudi Rocha ( Getulio Vargas Foundation, Rio de Janeiro, Brazil). China case study was undertaken by Jin Xu, Beibei Yuan ( Peking University School of Public Health, Beijing, China). Chile case study was undertaken by Cristóbal Cuadrado ( University of Chile, Santiago, Chile; University of York, York, UK), Alejandra Fuentes-Garcia, Ximena Barros, Maria Soledad Martinez, Jorge Pacheco ( University of Chile, Santiago, Chile). Ethiopia case study was undertaken by Mirkuzie Woldie Kerrie ( Addis Ababa University, Addis Ababa, Ethiopia), Girmaye Dinsa Fenot ( Harvard T.H. Chan School of Public Health, Boston, MA, USA), and Kiddus Yitbarek ( Ministry of Public Health, Addis Ababa, Ethiopia). Ghana case study was undertaken by Eugenia Amporfu, Eric Arthur ( Kwame Nkrumah University of Science and Technology, Kumasi, Ghana). India case study was undertaken by V R Muraleedharan ( Indian Institute of Technology Madras, Chennai, India) and Shankar Prinja ( Post Graduate Institute of Medical Education and Research, Chandigarh, India). Philippines case study was undertaken by Leizel Lagrada-Rombaua, Joyce Encluna, Emanuel Gloria ( GECC Development Services, Pasig City, Philippines). Estonia case study was undertaken by Kaija Kasekamp, ( PhD candidate, University of Tartu, Tartu, Estonia); Triin Habicht, ( WHO Barcelona Office for Health System Financing, Barcelona, Spain); Ruth Kalda ( University of Tartu, Tartu, Estonia). Finland case study was undertaken by Ilmo Keskimäki ( Research Professor, Finnish Institute for Health and Welfare, Helsinki, Finland; and Professor of Health Services Research, Tampere University, Tampere, Finland). New Zealand case study was undertaken by Jacqueline Cummings ( Independent Health Services and Policy Consultant, Wellington, New Zealand). Shaheda Viriyathorn, Anond Kulthanmanusorn, Walaiporn Patcharanarumol, and Viroj Tangcharoensathien ( International Health Policy Program, Ministry of Public Health, Bangkok, Thailand) provided additional data for sections 2 and 4. Research assistants that contributed to this Commission were Mazvita Briony Pasipanodya, The London School of Hygiene & Tropical Medicine, London, UK; Manon Haemmerli, The London School of Hygiene & Tropical Medicine, London, UK; Lauren Hashigushi, The London School of Hygiene & Tropical Medicine, London, UK; F Felipe Vera, Pontificia Universidad Católica de Chile, Santiago, Chile; Henry Cust, The London School of Hygiene & Tropical Medicine, London, UK; Rotimi Alao, The London School of Hygiene & Tropical Medicine alumni; Kevin Pene, The London School of Hygiene & Tropical Medicine alumni; Swati Srivastava, Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg, Germany. Experts consulted on political economy analysis were Thomas Lavers ( Senior Lecturer in Politics and Development, The Global Development Institute, The University of Manchester, Manchester, UK), Carlos Oya ( Professor of political economy of development, School of Oriental and African Studies, University of London, London), Susan Sparkes ( WHO, Geneva, Switzerland) and Julia Ngozi Chukwuma ( Open University, Milton Keynes, UK). For the provider payment survey of low-income to middle-income countries, Alexandra Michele Beith ( World Bank), and Agnes Munyua ( R4D) contributed to survey design, piloting, and implementation. Advice and assistance in accessing expert respondents were provided by Matthew Jowett ( WHO) and Julia Sallaku ( WHO). Becky Wolfe ( Independent Consultant) copy edited all case study reports. Figures and diagrams were developed by Joanne Duffy ( London School of Hygiene & Tropical Medicine) and Becky Wolfe. Anya Levy Guyer, Boston, MA, USA, was freelance technical writer and copy editor for this Commission. The Commission Manager was Brigid Strachan.
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Public financing for primary health care is the key to universal health coverage and strengthening health securityThe last time global leaders met in person to discuss health issues was at the UN high-level meeting on universal health coverage ( UHC) in New York, NY, USA in September, 2019. At this gathering, heads of government re-committed themselves to the Sustainable Development Goal 3, which aims to ensure that everyone can receive the health services they need without suffering financial hardship. Full-Text PDF Open AccessCommitment and innovation on the road to people-centred PHC financingThe Lancet Global Health Commission on financing primary health care ( PHC) 1 recognises that adequately financing PHC will be crucial to meet the target of SDG 3—ie, to ensure healthy lives and promote wellbeing for all at all ages by 2030.2 However, we still remain far off that goal, and the COVID-19 pandemic has set us back even further, badly disrupting many essential services that were not directly related to COVID-19, particularly in the realm of PHC such as mental health and maternal and child health. Full-Text PDF Open AccessAn assertive, practical, and substantive agenda to catalyse meaningful changeThe Lancet Global Health Commission on financing primary health care1 combines a shared vision with practical guidance on how to align health financing with overall reform strategies that place primary care service delivery at the core. The Commission reinforces key messages that WHO has put forward on health financing reforms to enable progress towards universal health coverage ( UHC). It then extends these by application to primary care as a critical service delivery element for the progressive realisation of UHC. Full-Text PDF Open AccessProvider perspectives on financing primary health care for universal health coverageHealth is seen as complete physical, mental, and social wellbeing, with good quality primary health care ( PHC) characterised as first-contact care that is comprehensive, continuous, and coordinated.1,2 Universal health coverage ( UHC) must be linked to service delivery that is organised around people's needs, integrating public health with primary care and including the private sector. Unfortunately, many health systems, especially in low-income and middle-income countries ( LMICs), are still centralised and bureaucratic. Full-Text PDF Open AccessFinancing primary health care: seeing the bigger pictureThe current COVID-19 crisis has exacerbated pre-existing distortions and exposed underlying weaknesses in the health system. Countries that have invested sufficiently in primary health care ( PHC) have responded more effectively to COVID-19 because they have a foundation on which to build essential public health and health security functions.1–3 Full-Text PDF Open Access | tech |
The cost of switching off Russian gas keeps on rising | Before the invasion of Ukraine, Russian gas was relatively cheap, easy to transport and in ample supply.
Europe’ s ambitious timetable for building its way out of a dependence on Russian energy faces potential delays and billions of euros in extra costs as the war in Ukraine makes steel, copper and aluminum scarce and more expensive.
A rush to replace Russian fossil fuels is prompting the continent to focus on shoring up flows of liquefied natural gas ( LNG) in the near term and increasing generation from renewable sources by 2030. Germany pledges to build two LNG terminals, France wants to resume talks with Spain about a connecting pipeline, and the UK seeks more homegrown wind, solar and nuclear power.
Yet prices for the necessary materials keep heading in one direction. Steel, copper and aluminum each touched records in the past 12 months, and the spikes threaten to slow such undertakings as the EU’ s blueprint to almost triple wind and solar capacity this decade - a colossal investment that could require about 52 million tons of steel alone.
“ This war has an impact, of course, on all those companies, including us, that are on the doorstep of making quite large-sized investments, ” said Fred van Beers, chief executive officer of SIF Holding, which makes steel platforms for wind turbines. “ It’ s putting our business case upside down, ” he said.
Nord Stream 2 pipeline
Before the invasion, Russian gas was relatively cheap, easy to transport and in ample supply. Those factors, plus the anticipated opening of the Nord Stream 2 pipeline to Germany, helped persuade Europe to reduce its own production.
The EU imported about 155 billion cubic meters of gas from Russia last year, according to the International Energy Agency. In the aftermath of war, the EU wants to cut dependency by two-thirds this year.
About 30 billion cubic meters can be replaced by other suppliers, with the difference made up by renewables, nuclear and changes in consumption, the IEA said. For the EU, the price for the infrastructure may be as much as 20% higher than before the war started, said Grant Sporre, an analyst at Bloomberg Intelligence. The European Commission’ s transition plan involves installing 290 gigawatts of wind and 250GW of solar. The bill just for the steel amounts to €65bn at current market prices.
Russia and Ukraine are among the biggest exporters of steel slabs used in building turbines and gas pipelines. While alternative sources are possible, costs for those are 50% higher than normal, according to Rysted Energy. Compounding the problem is China’ s decision to lock down its steelmaking hub of Tangshan in an effort to control a Covid-19 outbreak.
Copper is another vital ingredient, with high conductivity that’ s ideal for internal wiring and external cables. Europe requires about 7.7 million tons to meet its 2030 target, and this year’ s rally adds about €6.9bn to the price tag, according to Bank of America. | general |
SeXX and Immunity event raises crucial questions for society | Why are females more likely to survive Covid-19 but at greater risk of developing chronic disease? Historically, why have women and nonbinary people typically been excluded from clinical trials? How do we understand how sex differences affect everyone? What is the interplay between sex chromosomes and sex hormones?
Why has it taken the scientific community so long to include sex as a biological variable in research and analysis as a routine matter of course?
These were a few of the questions prompting lively discussion during the March 2 inaugural event for the SeXX and Immunity series, hosted by MIT’ s Department of Biological Engineering; the Ragon Institute of MGH, MIT and Harvard; and MIT’ s Center for Gynepathology Research. Sabra Klein of the Johns Hopkins Bloomberg School of Public Health anchored the event with a seminar about sex differences in immune responses to viruses and vaccines, with 180 attendees participating, in person and virtually.
The SeXX and Immunity community brings together basic and translational sciences and academia and industry science to address knowledge gaps head-on. By exploring the impact of female and male biology — both hormones and chromosomes — on normal and pathological immune responses to infection and other immune triggers, SeXX and Immunity participants aim to raise awareness about the crucial importance of considering the differences between male and female biological sex in clinical decision-making, and define specific problems that need attention — then mobilize the entire research community to address them efficiently.
Klein explained how crucial it is to consider the differences between male and female sex in clinical decision-making. However, in recent decades, clinical trials have not always adequately enrolled women or nonbinary people, or analyzed sex-specific differences in the data. This omission has hindered the progress of understanding not only of women’ s reproductive health, but both male and female responses to medications, immune disorders, infectious disease, cancer, neurological diseases, and more.
“ Females are more likely than males to survive SARS-CoV-2 infection, ” Klein explained. She highlighted this and many other findings of her recent work addressing the observed sex differences in the outcomes of Covid-19, adding “ The findings were consistent across diverse countries and cultural norm differences. ”
Dozens of attendees also attended a post-seminar networking and poster event on the MIT campus, which included an interactive panel discussion about research challenges and funding in sex-based disease research.
During the panel discussion, one attendee asked, “ How is it 2022 and we’ re just now launching a seminar series looking at sex differences in the immune response? What took so long? ”
Panelists explained the historical setting of women of reproductive age getting excluded from clinical trials decades ago, forcing researchers to adopt the assumption that everything could be extrapolated from studying males, and the harm these assumptions have caused.
In a post-event feedback survey, one attendee wrote, “ This discussion raises the fundamental questions about the importance of including sex in our research and analysis. ”
Another attendee shared that “ we have almost no idea how oral contraceptives, or other hormone-modifying medications, impact immune responses! This has to change. ”
At the networking event, attendees enjoyed discussions with Klein, poster presenters, other panelists, and each other. One attendee described the atmosphere as “ electric, ” and another shared that the March 2 event had heightened his interest in this topic from “ moderate ” to “ high. ”
Klein is an expert on sex and gender differences in immune responses and susceptibility to infection. She currently has over 130 peer-reviewed publications, authored several book chapters, and edited two books on the broad topics of sex differences in response to infection and treatments for infectious diseases. During the current Covid-19 pandemic, Klein has written commentaries for several journals and been interviewed by several major news media outlets about male-biased disease outcomes.
The SeXX and Immunity series is made possible due to the generous support of the Huiying Memorial Foundation.
Michal “ Mikki ” Tal is an instructor and team lead at the Institute for Stem Cell Biology and Regenerative Medicine at Stanford University and a visiting scientist at MIT Department of Biological Engineering.
Linda Griffith is the School of Engineering Teaching Innovation Professor of Biological and Mechanical Engineering and MacVicar Fellow at MIT, where she directs the Center for Gynepathology Research.
Doug Kwon is a physician scientist and director of clinical operations at the Ragon Institute of MGH, MIT and Harvard. He has a clinical practice in the division of Infectious Diseases at Massachusetts General Hospital.
Katy Bowman is postdoc at the Ragon Institute in the laboratory of Galit Alter. She is studying antibodies and Fc-mediated immune functions in niche compartments across multiple pathogens, including Lyme disease, SARS-CoV-2 infection, and tuberculosis. | business |
Tax Day is coming soon. Here's what you need to know about filing your 2021 taxes | Soaring inflation. The war in Ukraine. Yet another rise in Covid cases. With so much going on this year it's hard to focus on
things like filing your taxes.
Nevertheless, the IRS still expects you to file your 2021 return and pay whatever you still owe by the filing deadline, which is April 18 for most taxpayers.
If you haven't filed yet, here are answers to some key questions that will help you through the process:
Do I have to file by April 18th?
Ideally, yes. But if that proves difficult -- or you're just not in the mood -- file for an automatic six-month extension by using
Form 4868
.
Read More
Of course, there are some taxpayers whose filing deadline is later than April 18. They include residents of Maine and Massachusetts, whose official filing date is April 19. And the deadline is a month or more later for people living in
federally declared disaster areas
, as well as US taxpayers living outside of the United States on April 18.
If I do owe money, when is that due?
For most people, you have to pay any remaining 2021 income taxes that you
still owe
by the April 18 filing deadline, even if you get an automatic
six-month extension to file.
What if I don't pay on time?
You will have to pay even more than you owe, because you 'll be slapped with
penalties and interest.
If you really can't afford to pay on time, and you have a good reason for why, you can make your case to the IRS by attaching a statement to your return when you file. If the IRS accepts your explanation, it may waive the
late payment penalty
. At a minimum, you need to show that your failure to pay is not the result of ``
willful neglect
. ''
To show that, try to pay what you can when you file, even if it's not the total balance. If that's not possible and you're really behind, you may be able to set up a
repayment plan
with the IRS.
What if the IRS owes me money?
If you file an accurate return electronically, and are owed a refund, the IRS will likely have that money sent to you or direct deposited into your bank account within 21 days of receiving your return.
You can check the status of where things stand by using the IRS online tool
Where's My Refund?
I was working remotely for much of 2021. Will that affect my taxes?
It depends. If you worked from a state other than the one where your employer is based, you could be subject to the income tax rules of two or more states.
At the very least you 'll likely have to file more than one state tax return for 2021, which will cost you more if you're paying someone else to prepare your taxes.
And in some instances -- primarily involving five states that have so-called convenience rules -- you may even be double-taxed on the same income.
( Learn more
here
.)
The advanced child tax credit is so confusing. How should I handle that on my tax return?
Good news: You are
not
imagining things. The child tax credit is causing
headaches for both filers and tax pros
alike.
There were a lot of temporary changes made to the child tax credit just for 2021. For starters, it was raised to $ 3,600 per child ages 5 and under, and to $ 3,000 per child ages 6 through 17.
It was also temporarily made fully refundable for 2021, meaning you can get the maximum amount of the credit even if it exceeds your federal income tax liability.
But here's where the real confusion comes in: The IRS likely has already sent you half the credit you're entitled to ( six months ' worth) through monthly checks sent out between July and December.
You should have gotten a
letter from the IRS
in the past couple of months detailing what you 've been paid already. That's an amount you will need to report on your return. And then you will have to claim the other half of the credit you're owed, which you will get by way of
a refund
.
( Learn more
here
.)
I got an IRS letter saying it sent me a stimulus check. Is that reportable and taxable?
The IRS recently mailed
Letter 6475
to taxpayers who received a
third round stimulus payment
, which the agency started sending out in March 2021.
While the payment isn't taxable, you should report the number from that letter on your 2021 return. The last thing you want is for there to be a discrepancy between the IRS records and what's on your return. That will cause
delays
in processing your return and issuing your refund.
And you 'll want to use that number to work out whether the IRS actually owes you more by way of a
recovery rebate credit
, once you calculate how much more of the stimulus payment you're due on the basis of your actual 2021 income.
I have cryptocurrencies. Do I have to report that?
It depends.
Just buying and holding cryptocurrencies are not taxable events.
But if you sold cryptocurrencies, used them to buy something or were paid in crypto, those are taxable events and
must be reported
.
Virtual
currencies are taxed as property, or as an
investment
, when you sell
them. To make matters more confusing, using them to buy something technically counts as selling. So you will be subject to capital gains tax when you sell them.
If you're paid in
bitcoin or other crypto, on the other hand, that will be treated as
taxable income
to you. So will income earned from mining or staking.
And starting next year your crypto activities will be
subject to third-party reporting
-- meaning both you and the IRS will get the same tax forms reporting your sales and income.
I can't get through to the IRS and have a question. What should I do?
It's been very
difficult
for taxpayers and tax pros alike to reach the IRS by phone because the agency is too understaffed to handle the volume of calls.
If you 've already invested time combing through the information resources on IRS.gov to find an answer to your question, you might consider an in-person visit to a Taxpayer Assistance Center near you.
Normally you need to make a weekday appointment. But the IRS announced that many of its Taxpayer Assistance Centers will be open to walk-ins on the second Saturday of each month through May.
You can find your local office
here
. Call first to make sure they 'll be open on the day you want to go. | general |
Asylum seekers lodge 153 complaints against direct provision centres | The International Protection Accommodation Service received 153 complaints last year about standards or other issues faced by asylum seekers. Picture: Eamonn Farrell/RollingNews.ie
Lack of privacy, rules requiring the wearing of masks, and food that was too spicy were among official complaints made last year about direct provision centres.
The International Protection Accommodation Service ( IPAS) received 153 complaints last year about standards or other issues faced by asylum seekers.
The highest number of complaints ( 48) were made about accommodation staff or management while 37 were logged over issues with accommodation.
There were 35 complaints registered regarding issues between residents and another 11 were made about where people were being housed, requests to move, or plans to transfer them to another centre.
Ten grievances were filed about house rules or centre operations, while three complaints were received from a third party.
Records also reveal four complaints about Covid-19 public health measures and sixteen complaints lodged about culinary preferences or the standard of food.
The IPAS also logged four complaints about missing or lost property, and four about transport arrangements available to centre residents.
One complaint was transferred to another public body, according to the record, while four grievances were categorised as “ miscellaneous ”.
A detailed log of three months of complaints reveals the type of issues that arose for asylum seekers living in direct provision centres.
Cases | general |
Schiphol Airport addresses the industry’ s biggest challenge – climate change | As a result of the impact of Covid-19, Amsterdam’ s Schiphol introduced a reorganisation programme dubbed Project Reset, to recover from the implications of operating with fewer passengers and flight movements and impacted financial results leading to necessary cuts to costs.
By Jasleen Mann
The steps which are being taken by the airport to restore their position align with sustainability expectations within the industry. Schiphol will focus on innovation with regards to digitalisation as well as sustainability.
A Schiphol spokesperson says: “ Our reorganisation programme, Project Reset, helped us improve as a company and adapt to our much-changed operating environment.
“ Project Reset has led us to reprioritise our investment portfolio and operational expenditures and to make structural improvements to mitigate the anticipated longer-term impact of Covid-19 on demand for air travel. ”
Significant developments relating to the airport’ s sustainability efforts include the implementation of electric ground power units. Regardless of whether a plane is parked at the gate or on the apron, electricity is needed to ensure that the systems on board continue to function.
Related
Traditionally, special diesel generators have been used in this regard but the airport has adopted a new method in order to reduce emissions and improve air quality. Currently, 73 of the 128 gates at Schiphol are using fixed electric power units for planes and the airport aims to install more so that all 128 gates have access to this technology.
Schiphol collaborated with industrial company ITW to develop an electric and portable generator, the electric ground power unit ( e-GPU), to replace the diesel generators which were traditionally used.
In addition, new technology was also implemented in the form of TaxiBots which also contribute to the reduction of emissions and improvements to local air quality.
The TaxiBots are special towing vehicles that make it possible for aircraft to taxi in a sustainable manner. Sustainable taxiing entails taking aircraft to and from the runway through use of the Taxibot which means aircraft engines can be largely switched off during taxiing.
The spokesperson says: “ Royal Schiphol Group’ s ambition is to operate the world’ s most sustainable, high-quality airports. We continue to invest in safety, quality, sustainability and innovation.
“ For example, Schiphol’ s capacity-related investments include steps to improve Schiphol’ s landside access road system, the construction of a new pier and the redevelopment of Lounge 1.
“ Furthermore, we are doubling the Quebec taxiway to further improve safety and efficiency. In all our investments, sustainability and circularity are embedded. ”
The Schiphol terminal is surrounded by taxiways that serve departing and arriving aircraft. While almost all of the taxiways have two lanes, the ring they are supposed to form is incomplete at the moment. Quebec is currently a single lane taxiway between the Kaagbaan Runway and Zwanenburgbaan Runway.
Developing Quebec as a dual taxiway will entail building another aircraft bridge over the A4 motorway. When it is completed, the new system will enhance management of air traffic control and remove wait times for aircraft.
Schiphol has been focused on reducing natural gas and energy consumption for a long time, with the airport running on 100% Dutch wind energy since 2018.
Most of the terminal, most piers and a number of offices have a heat and cold storage which stores energy in the form of heat and cold in the ground. As a result, Schiphol uses less natural gas to heat and cool these buildings.
“ Recently we joined the movement to lower the heating, by dropping the temperature at Schiphol by one degree in the terminal and at the head office.
“ Because of the war in Ukraine, we are willing to become less dependent on natural gas, which is also good for the environment and saves money, ” says Schiphol’ s spokesperson.
The amount of money saved by the Schiphol Group, as a result of their efforts to lower heating, will be donated to Giro 555 which is a Dutch donation fund for the war in Ukraine.
Schiphol’ s spokesperson adds: “ Aviation’ s biggest challenge is the climate crisis and the pace at which the sector can be made more sustainable. It can be done, but it needs to be done faster.
“ The aviation sector needs to have achieved net zero by 2050 – that commitment is clear. But we need to move as swiftly as possible now, in these first few years. | general |
I 'm a Dublin scientist and I discovered a new Covid strain in the sewers of New York | Irish microbiologist Davida Smyth believes mass vaccination on a scale similar to that for polio is the only way we can continue to live with Covid-19.
When Irish microbiologist Davida Smyth signed up for Twitter, she may never have expected to be an ardent follower of a “ Covid poops ” account.
The global dashboard @ COVIDPoops19 is a platform for “ all things wastewater ” and Sars-CoV-2, and has proved to be an invaluable communication tool for scientists such as her.
The handle has retweeted some of Smyth’ s own research with colleagues on mysterious new strains of coronavirus in the New York public sewage system.
Smyth, who is an associate professor of molecular microbiology at the Texas A & M University-San Antonio, is joint author of a paper recently published in the scientific journal Nature Communications on the results of that research.
As she explains, testing wastewater has always been an invaluable and economically efficient way of tracing and tracking harmful bacteria, such as E.coli.
About five months after Covid-19 hit the US, Smyth collaborated with a group of scientists at the City University of New York who were commissioned to test wastewater in conjunction with the city’ s department of environmental protection.
The work with colleagues involved analysing DNA sequencing on the virus and watching out for differences that would indicate an increase in cases and the possible evolution of new variants.
This involved using tiny filters to separate out the virus from the water, and converting the coronavirus spike RNA to DNA, where it was then isolated and sequenced.
When the Omicron variant was reported in South Africa, the team began looking for it in the wastewater systems and detected it two weeks before it was confirmed in Covid patients in New York.
Last January they also began to observe something unusual — four variants or “ cryptic lineages ” that had not so far been detected by clinical health teams in New York.
So where were these new variants coming from? This was the million-dollar question, Smyth says.
Some of the scientists suggested it could be linked to animals with the virus, from dogs and cats to squirrels and rats.
Others, such as Smyth, suspect the variants may be linked to people whose infections are not being tracked by established detection systems.
“ We were sampling from 14 wastewater plants and these new variants were coming from a handful of the plants, ” she explains.
“ We were aware that Omicron was detected first in South Africa, where there is a high incidence of HIV-Aids.
It could be that these new variants are linked to specific immune-compromised patients treated in one or two clinical settings, or it could even be that these variants are being created and shed by one single person.
The research highlights the value of studying wastewater systems as a cheaper and faster way of keeping on top of the virus, she says.
“ Instead of testing individuals for variants, a wastewater sample covers thousands, ” she explains.
The information allows local authorities to act quickly when a new strain emerges, allowing for specific quarantining, Smyth explains.
“ Ireland is doing well at this and it’ s important because Covid-19 is not going away any time soon, ” she says.
Ireland has over 1,100 public wastewater catchment areas. A surveillance programme involving 68 of these across every county began last May under the leadership of Professor Wim Meijer of University College Dublin’ s School of Biomolecular and Biomedical Science.
“ A national wastewater surveillance system has been set up in the US, but not enough authorities have bought in as it requires funding, ” Smyth says.
She is involved in a similar monitoring programme in San Antonio, which has a special relationship with water as it relies on a single aquifer, she explains.
The monitoring project will provide opportunities for her students to become involved and learn from invaluable practical research.
Smyth, who is originally from Dublin’ s Stoneybatter — “ before it got trendy ” — studied at Trinity College Dublin but has strong Cork connections at a professional level.
| general |
Auto mechanic shortage, delays seen growing | The auto technician field will see a 4 percent drop in the number of people in the work pool through the end of the decade — but the wave of retiring baby boomers will result in 100,000 tech job openings over the next decade or so, according to a recently released report.
CCC Intelligent Solutions’ annual Crash Course report, which analyzes data to spot trends in the automotive and repair industries, said the resulting staffing shortages will lead to longer collision repair times.
The average backlog for collision repair grew from 1.2 weeks in the fourth quarter of 2020 to 3.4 weeks during the same period in 2021, the report said. The average time for collision repair increased from 8.5 days to 10.6 days. And the average price for repair parts grew from $ 122 in 2019 to $ 136 in 2021.
Report author Susanna Gotsch, senior director and industry analyst at CCC, said the combination of the COVID-19 pandemic, parts supply shortages, rising inflation, staffing issues, cutting-edge vehicle technology and shifting driving behavior has “ forever changed ” the automotive, claims, repair and collision industries.
“ It’ s perhaps one of the most challenging periods ever for businesses, but also one of the most exciting, ” Gotsch says.
Read the full report at cccis.com. | general |
Commitment and innovation on the road to people-centred PHC financing - The Lancet Global Health | The Lancet Global Health Commission on financing primary health care ( PHC) 1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; ( published online April 4.) https: //doi.org/10.1016/S2214-109X ( 22) 00005-5Google Scholar recognises that adequately financing PHC will be crucial to meet the target of SDG 3—ie, to ensure healthy lives and promote wellbeing for all at all ages by 2030.2United NationsSDG Goal 3.https: //sdgs.un.org/goals/goal3Date accessed: March 22, 2022Google Scholar However, we still remain far off that goal, and the COVID-19 pandemic has set us back even further, badly disrupting many essential services that were not directly related to COVID-19, particularly in the realm of PHC such as mental health and maternal and child health.3WHOGlobal spending on health 2020: weathering the storm. World Health Organization, Geneva2020Google Scholar And with an uneven global economic recovery, many countries ' health budgets will face a period of austerity.4Kurowski C Evans DB Tandon A et al.From double shock to double recovery: implications and options for health financing in the time of COVID-19. Health, Nutrition and Population Discussion Paper. World Bank, Washington, DC2021Google Scholar
The Commission highlights that the way health care is financed, particularly PHC, is exclusionary and underfunded. It calls for countries to invest more and better in PHC. The most progressive way to fund PHC is by mobilising additional pooled public funding. This is because out-of-pocket payments in low-income and middle-income countries ( LMICs) are the most significant barrier in access to health care yet they still remain the largest share of public financing in low-income and lower-middle-income countries at 41% and 42%, respectively.3WHOGlobal spending on health 2020: weathering the storm. World Health Organization, Geneva2020Google Scholar In most LMICs, it is argued that additional public funding can be mobilised through increasing general tax revenue that is then allocated to PHC. However, the weakness in tax revenue mobilisation in low-income countries means a reduced capacity to fund public spending compared to higher-income countries—the mean tax–GDP ratio in low-income countries is 12%, compared with nearly 30% in high-income countries.5International Monetary FundWorld Revenue Longitudinal Data ( WoRLD). International Monetary Fund, Washington, DC2021Google Scholar The additional tax could be generated by improving the collection of existing taxes, increasing the tax base, and expanding the number and types of taxes levied. The Commission recognises that LMICs face significant challenges collecting tax revenues, thus we need to introduce more progressive taxation such as increasing solidarity levies for financing PHC in LMICs, akin to the funding structure of UNITAID, which has raised US $ 1·25 billion from hypothecating airline taxes to global health. Additionally, international cooperation is needed to tackle illicit financial flows, which, according to the United Nations Conference on Trade and Development ( UNCTAD), amounts to $ 88·6 billion every year in Africa alone.6UNCTADTackling illicit financial flows for sustainable development in Africa. United Nations Publications, New York2020Google Scholar
Another problem the Commission mentions in financing PHC is the inadequate, declining, and fragmented donor funding. While LMICs can explore ways to increase their tax revenue to pool public resources together, donor funding for health is essential for low-income countries. Yet donor funding typically neglects the whole-of-society approach to health essential for PHC in favour of targeting specific disease programmes—in low-income countries an average of 65% of donor assistance is allocated to infectious and parasitic diseases and donor contributions tend to operate off-budget, undermining the ability for health ministries to plan and manage these resources alongside domestic funding to fund PHC.3WHOGlobal spending on health 2020: weathering the storm. World Health Organization, Geneva2020Google Scholar Nonetheless, bilateral and multilateral aid remains essential in low-income environments until at least 2030, and with improvements in PHC expenditure data, donors could increase funding for PHC through an improved global system of multilateral support that weans the donor community off vertically-supported programmes and towards routine services.
However, with aid and tax revenue not enough to meet the global health financing shortfall, there need to be alternatives to increase the overall envelope of borrowing in LMICs. Typically LMICs are reluctant to acquire more debt to invest in health care and other global public goods because the current form of deficit financing is more suitable for capital rather than recurrent expenditures. Therefore, to help LMICs finance PHC we ought to consider creating an innovative financing facility for health that is able to leverage guarantees from high-income countries, which, combined with grants, could raise significantly more additional resources for poorer countries than traditional forms of borrowing from multilateral development banks.7The Education CommissionThe International Finance Facility for Education ( IFFEd). The Education Commission, New York2021Google Scholar The COVID-19 pandemic was a revelation in showing the importance of health funding in LMICs, so now this window of opportunity must be capitalised on by creating more innovative forms of borrowing for LMICs that can leverage more and provide the funding at an affordable rate.
Ultimately, to be able to take on more financing, LMICs will need to commit to a sectoral plan for PHC and the overall health-care sector while committing to reform and investment. The Lancet Global Health Commission recommends that countries adopt a blended payment model, adaptable to country context but with capitation at its centre, to prioritise reducing out-of-pocket payments. Governments should also commit to tackling the inefficiencies in health spending—the 2010 World Health Report stated that there were inefficiencies equivalent to 20–40% of health spending.8WHOThe world health report: health systems financing: the path to universal coverage. World Health Organization, Geneva2010Google Scholar Improvements in digital technologies offer hope in reducing the inefficiencies in health spending by providing more data. However, the most effective way to increase the health budget is through the government budget, and that requires the political will to start prioritising health budgets more, and new forms of innovative finance can encourage that political will by providing more resources at a concessionary rate.
We declare no competing interests.
The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care ( PHC) into sharp focus. PHC is the best platform for providing basic health interventions ( including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open Access | tech |
Application security market to reach $ 13.1 billion by 2025 | The potential growth difference for the application security market between 2020 and 2025 is $ 13.1 billion, as per the latest market analysis report by Technavio. The report also identifies the market to register an accelerating growth momentum at a CAGR of 26%.
The growing number of data leaks is one of the key application software market driving the market’ s growth. Cyber thefts and crimes are growing at an alarming rate. The number of data leaks by hackers is rising globally. For instance, amid the COVID-19 pandemic majority of the companies across the world witnessed an increase in cyberattacks.
The application security helps enterprises to review the critical areas of concern within their environment and provides insights and offers tools to defend against these attacks.
The threat from open-source application security solutions will be a major challenge for the application security market during the forecast period. Open-source application security solutions are posing a severe threat to the application security market. They can be downloaded and run on all platforms and are becoming increasingly popular in developing countries.
Most small-scale enterprises opt for open-source application security solutions. The increasing adoption of open-source application security solutions is reducing the overall revenue of the application security market.
The web application security solution segment held the largest application security market share during the forecast period. The web application security segment is expected to witness growth, as many enterprises are using web applications to carry out their businesses. Enterprises are increasingly deploying various web applications in their businesses, which is expected to drive the segment in the forthcoming years.
North America will be the leading region with 45% of the market’ s growth during the forecast period. 45% of the market’ s growth will originate from North America during the forecast period. US and Canada are the key markets for application security in North America. Market growth in this region will be faster than the growth of the market in other regions. The growing security threats will facilitate the application security market growth in North America over the forecast period.
I have read and agree to the terms & conditions | tech |
BOJ should pay attention to yen, ruling coalition lawmaker says | The Bank of Japan should pay close attention to currency levels because its efforts to hold down interest rates are weakening the yen, according to a senior member of the Japanese ruling coalition party Komeito.
“ From the point of view of the economy, I understand why they are holding down interest rates, ” said Keiichi Ishii, secretary-general of Komeito, the junior partner to Prime Minister Fumio Kishida’ s ruling Liberal Democratic Party.
“ But the side effects of that are reflected in exchange rates, ” he said in an interview with Bloomberg News in Tokyo on Friday. “ How far can the side effects be tolerated? If the yen goes too low, things will be tough, so I want the BOJ to pay close attention to exchange rates. ”
The central bank has been forced repeatedly to scoop up more Japanese government debt as the global sell-off in bonds put pressure on Japan’ s yields. The differential between U.S. and Japanese yields helped push the yen as low as 125 against the dollar last week for the first time since August 2015.
Weakness in the yen is amplifying the impact of soaring energy prices that are squeezing households and businesses, a factor that could fuel discontent among voters ahead of a summer election.
While Komeito’ s No. 2 didn’ t specify what the central bank should do if the yen weakens further, some BOJ watchers see the possibility of the bank tweaking policy by raising the ceiling on 10-year yields through a widening of its bond yield target range.
“ In the past, a cheaper yen was seen as a benefit for Japan’ s exporters, but at this point it’ s coming as prices for various things are starting to rise, ” Ishii said. “ It could worsen already rising prices, so the lower yen is starting to become negative. ”
While Japan’ s inflation rates remain low by comparison with other major economies, the sharply higher fuel prices are putting pressure on lower-income households, who form a key constituency for the Buddhist-backed Komeito party.
Ishii spoke amid speculation over who will replace Haruhiko Kuroda at the head of the bank and whether a new governor would change policy. Kuroda’ s decade in office is set to end in a year.
The next governor must be someone able to achieve a successful exit from its policies, Ishii said. He emphasized the selection is up to the government and the ruling parties can do nothing more than make their wishes known.
“ The current policies of Mr. Kuroda can not be continued indefinitely into the future, ” he said. “ The next governor will need to seek an exit. So we need someone who can do that skillfully. ”
While the LDP has an outright majority in the powerful Lower House of parliament, it has an agreement to consult on policy with its partner Komeito. The group often mobilizes its members to support the LDP in constituencies where it doesn’ t have a candidate, and an upper house election is due in three months.
Ishii’ s party has called on the government to draw up an extra budget in the current session of parliament to help bolster the economy, amid uncertainty over the effects of the war in Ukraine and a resurgence of COVID-19 cases.
Kishida instructed officials last week to draw up economic measures aimed at countering the effect of sharp rises in fuel and other prices that could undermine voter support ahead of the election.
The government will initially focus on using reserves to introduce such measures quickly, he told parliament. | tech |
China gas buyers seek cheap Russian fuel shunned by the world | China’ s top liquefied natural gas importers are cautiously looking to purchase additional Russian shipments that have been shunned by the market in a bid to take advantage of cheap prices.
State-owned companies including Sinopec and PetroChina are in discussions with suppliers to buy spot cargoes from Russia at a deep discount, according to people with knowledge of the matter. Some importers are considering using Russian firms to participate in LNG purchase tenders on their behalf to hide their procurement plans from overseas governments, the people said.
Most LNG importers around the world won’ t buy Russian cargoes out of fear of future sanctions or damage to reputation, as the war in Ukraine drags on and the European Union ratchets up pressure against Moscow. Chinese firms are emerging as some of the only companies willing to take on that risk.
PetroChina declined to comment. Sinopec didn’ t immediately respond to a request for comment during a holiday.
This mimics a similar move by China’ s oil refiners, which are also discreetly purchasing cheap Russian crude that the rest of the world doesn’ t want. Several LNG shipments were already purchased by Chinese importers in the last few weeks, traders said.
Russian LNG is trading at more than a 10% discount to normal North Asia shipments in the spot market, according to traders. Spot prices for the super-chilled fuel surged to a record last month due to the war in Ukraine, which is tightening supplies just as global consumption rebounds.
To be sure, China isn’ t in dire need of LNG as milder weather and COVID-19 lockdown fears have curbed spot demand. Still, Russian gas at a deep discount can help top up storage tanks before prices rise again this summer.
China’ s LNG buyers are looking for the cargoes via bilateral discussions in order to keep a low profile in the spot market, according to the traders, who requested anonymity as the talks are private. And the companies remain cautious, choosing to withhold from buying large quantities.
Instead of participating directly in a Russian LNG sales tender, Chinese companies are looking to use so-called “ sleeves, ” or firms to buy on their behalf to mask their procurement, traders said. This will help mask their spot activity, and instead look like the Chinese company may be accepting a delivery of Russian gas from a long-term contract, which firms around the world have continued doing despite the war in Ukraine.
They are also avoiding participation from satellite offices from London to Singapore, to skirt any potential trouble with those governments. Most LNG trading desks for Chinese firms are located overseas.
There are still hurdles. Smaller Chinese LNG buyers are struggling to get credit guarantees from banks to purchase additional spot cargoes from Russia, with most institutions in Singapore unwilling to provide support. Only the top Chinese importers can use so-called open-credit schemes, which are preapproved lines of credit from banks. | tech |
Provider perspectives on financing primary health care for universal health coverage - The Lancet Global Health | Health is seen as complete physical, mental, and social wellbeing, with good quality primary health care ( PHC) characterised as first-contact care that is comprehensive, continuous, and coordinated.1World Health OrganizationDeclaration of Astana.https: //www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdfDate accessed: March 22, 2022Google Scholar, 2Starfield B Shi L Macinko J Contribution of primary care to health systems and health.Milbank Quarterly. 2005; 83: 457-502Google Scholar Universal health coverage ( UHC) must be linked to service delivery that is organised around people's needs, integrating public health with primary care and including the private sector. Unfortunately, many health systems, especially in low-income and middle-income countries ( LMICs), are still centralised and bureaucratic. In reorganising PHC, African health-care providers such as myself feel it is vital to bring care closer to people, with an empowered PHC team taking care of a well-defined population.3World Health OrganisationThe world health report 2008: primary health care—now more than ever.https: //apps.who.int/iris/handle/10665/43949Date accessed: March 22, 2022Google Scholar There are many challenges in doing this.
Providers feel that political commitment to PHC is not reflected in the funding of PHC—as if it can be done on the cheap. I therefore agree with the conclusions of the Lancet Global Health Commission on financing primary health care4Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; ( published online April 4.) https: //doi.org/10.1016/S2214-109X ( 22) 00005-5Google Scholar that funding and investment need to be increased and payment systems reorganised. Funds need to directly reach the PHC team on the ground without being waylaid by layers of managers and interests in between. Pooling of funding, including from donors, not only addresses equity but also reduces fragmentation of funding and service delivery. Adjustments in capitation rates ( ie, the amount paid to a provider to cover all services for a patient) can target equity—eg, by considering high-risk groups and the multimorbidity, rurality, or socioeconomic status of enrollees. Systems with centralised budgets nominally allocated to facilities make services unresponsive to the population served. Nationally defined mixed or blended capitation contracts offer great opportunity for PHC because enrollees can vote with their feet and change providers if they do not receive good quality care. A dominantly per-capita payment system is better suited to the complex biopsychosocial nature of PHC, which includes important elements of service that are hard to reimburse—eg, teamwork, community work, group work, or health promotion—than are fee-for-service payments.
Primary care providers struggle with the poor definition of primary care services within many LMICs, resulting in difficulty measuring the financial and human resource allocations needed. PHC services, especially the primary care service delivery platform, needs to be defined well and with ringfenced resources. The number of doctors, nurses, and other members of the PHC team available in the country is often not easily or reliably available. To compound the issue, governments often do not take their stewardship role over the private sector very seriously and have not created systems to measure the total number of professionals across the country, with planning merely based on public health service “ shortages ”.
Private health services are a threat to public services in many LMICs because they grow exponentially when populations are disaffected by what they see as a poor service in the public sector, further drawing out human resources into the private sector. Turning this back can be extremely difficult, but the situation offers a great opportunity if governments get ahead of the curve. Pooled funding, strategic purchasing, and mixed capitation payment systems not only create efficiencies in the public health service, but also draw the private sector into this more regulated environment, provided governments embrace a systems approach. Such systems can include private providers, services, and administrators but require less bureaucracy and a greater focus on simple outcomes.
A project by the South African National Treasury to test the feasibility of private general practitioner ( GP) capitation contracting for the planned National Health Insurance ( NHI) system in South Africa produced a design based on global best practice and consultation with the private sector. The project was reoriented to suit both public and private providers but using a bottom-up approach in contrast to current NHI plans for PHC. The plan started with a country estimate of the core of the PHC team: doctors, nurses, clinical associates, and community health care workers ( CHWs). It was estimated that a minimum team of one doctor, five nurses or clinical associates, and ten CHWs could care effectively for a panel of 10 000 patients. Enabling this would mean adding one doctor to public clinics and mostly solo GPs adding a team to their practices. With around 14 000 GPs and 1000 public medical officers in PHC in South Africa, just 6000 would cover the country's population of 60 million in a nationally defined mixed capitation contract, easily administered through private administrators in tendered markets across provinces in South Africa. Just 3000 GPs contracted could alter private sector dynamics, with knock-on effects to the costing of the overall NHI.5Moosa S Summary of proposed NHI capitation contract design.https: //profmoosa.com/summary-of-proposed-nhi-capitation-contract-design/Date accessed: March 10, 2022Google Scholar
In this design, the PHC team ( with an accountable doctor) is contracted, after accreditation, to provide services to up to 10 000 enrollees from within a district. Capitation payment covers all visits, estimated at an average of four per year based on private sector experience. Capitation payment dominates ( at 70% of resource envelope), with rates adjusted for equity; medicines, investigations, procedures, and a range of preventive services are paid by a defined fee-for-service ( at 20% of resource envelope); and an estimated 10% of resource envelope is allocated to payment of a performance management plan laid out over 5 years, to create a predictable change plan that progressively embraces electronic health records in a market-based system with interoperability requirements. Risk mitigation strategies need to address risks providers face, including high visit rates.6Moosa S Luiz JM Carmichael T Introducing a national health insurance system in South Africa: a general practitioner's bottom-up approach to costing.S African Med J. 2012; 102: 794-797Google Scholar These can be addressed with a strong community-oriented primary care approach, based on work in Soweto.7Moosa S Community-oriented primary care for National Health Insurance in South Africa.Afr J Prm Health Care Fam Med. 2021; 133243Google Scholar Management of risk for GPs, especially growth in organisational size, needs to be managed with progressive growth of the minimum 2000 panel size. Moral hazard, which might result in patients being denied access or over-referral, needs to be addressed through defined referral pathways, peer review, and training in family medicine.5Moosa S Summary of proposed NHI capitation contract design.https: //profmoosa.com/summary-of-proposed-nhi-capitation-contract-design/Date accessed: March 10, 2022Google Scholar
This design is informing the position by PHC team members across Africa, organised through the African Forum for Primary Health Care. Although countries across Africa differ in the availability of resources, the model of PHC teams taking care of defined populations is still relevant, with ratios of PHC team members to populations needing to be worked out per country. A key question is how governments and global organisations are helping PHC providers to explore such solutions where frontline health-care providers, especially professionals, are treated with respect and empowered to produce results in PHC as they are trained to. Forcing providers into capitation with low rates is a poor strategy. Instead, as Aneurin Bevan, in successfully overseeing the creation of the National Health Service in the UK, was quoted to say: “ I stuffed their mouths with gold ”.8Watt N Carvel J NHS puts squeeze on private medicine. The Guardian, 2004https: //www.theguardian.com/society/2004/jul/03/NHS.politics2Date accessed: March 10, 2022Google Scholar
I declare no competing interests.
The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care ( PHC) into sharp focus. PHC is the best platform for providing basic health interventions ( including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open Access | tech |
Right-winger Rodrigo Chaves wins Costa Rica presidency as rival concedes | San Jose – Right-wing former Finance Minister Rodrigo Chaves will take over as Costa Rica’ s new president on May 8 after winning Sunday’ s election, poised to oversee the challenge of reinvigorating the country’ s battered economy.
With 96% of the votes counted, Chaves held a close to 6 percentage point lead in provisional results over Jose Maria Figueres, the centrist former president, according to the Supreme Electoral Court ( TSE).
“ I receive with the deepest humility this sacred decision of the Costa Rican people … This result for me is not a medal or a trophy, but an enormous responsibility, ” the 60-year-old economist said to a crowd of supporters in the capital San Jose.
Figueres congratulated Chaves and wished him well in his concession speech.
“ Costa Rica has voted and the people have spoken. Since we are democrats we respect that decision, ” the 67-year-old said.
Unemployment and an economic crisis dominated the campaign between two scandal-tainted candidates relieved not to have their past indiscretions take center stage.
Chaves was once demoted for sexual harassment, while Figueres was previously investigated for corruption.
But with 23% of the population living in poverty and unemployment soaring to 14% alongside a series of corruption scandals, Costa Ricans seemed more focused on the economy as they elected the successor to President Carlos Alvarado.
Voting was carried out “ in peace and tranquility, ” said TSE spokesman Gustavo Ramon.
Presidential candidate Jose Maria Figueres concedes defeat during a speech after polls closed in Costa Rica’ s run-off presidential election between Figueres and former finance minister Rodrigo Chaves, in San Jose, Costa Rica on Sunday. | REUTERS
Chaves will take over from the unpopular Alvarado next month, faced with the major challenge of reigniting an economy in crisis.
Costa Rica has been described as the “ happiest ” country in Latin America and praised for its political stability, environmental policies and ecotourism.
But the vital tourism industry was hard hit by the coronavirus pandemic.
Alongside Peru, it suffered the largest fall in employment figures in the region between 2019 and 2020.
“ Costa Rican society was not poor, they made it poor. Costa Rican society was not unequal, they made it unequal, ” said Chaves, who voted in mid-morning at a school in the capital’ s city center.
Voters were very clear about what concerned them the most: the economy and employment.
“ The next president has to change everything because we’ re very poor. There is no work here, there is nothing, ” said Ana Briceno, 64, a travel agent in San Jose.
“ In the last years with Carlos Alvarado the situation has been very difficult … so I think the future president must focus on the economy, ” said Cristina Aguilar, 32.
Chaves was a surprise qualifier for Sunday’ s run-off, having polled fourth ahead of February’ s first round.
Representing the newly formed rightwing Social Democratic Progress Party, Chaves had led the most recent opinion polls with more than 41% support, compared to 38% for Figueres.
“ We have spoken about progression and rejecting regression, ” he said in a news conference.
Supporters of Rodrigo Chaves, Costa Rica’ s president-elect, cheer and wave flags during an election night rally following runoff presidential elections in San Jose, Costa Rica, on Sunday. | BLOOMBERG
His father Jose abolished the army in 1948 when he was president.
“ We have options to generate employment, which is what is most lacking, and to grow the economy, ” he said.
Figueres topped the first round of voting among a crowded field of 25 contenders with 27.3%, ahead of Chaves who had 16.8%.
But they were a long way from the 40% needed to win outright.
Both men have reached this final stage of the election despite the specter of past scandals.
Chaves, who spent six months as finance minister in the outgoing government, was investigated over sexual harassment complaints brought by multiple women while he was a senior official at the World Bank, where he worked for 30 years.
He was demoted, though not fired, and has dismissed his behavior as jokes that were “ misinterpreted due to cultural differences. ”
Figueres, who represents the centrist National Liberation Party ( PLN), was investigated for allegedly taking $ 900,000 from French engineering firm Alcatel, which has admitted to bribing officials.
The ex-president, who worked abroad at the time as executive director of the World Economic Forum ( WEF), refused to give evidence in the case in 2004 and returned to Costa Rica only in 2011 when the investigation expired. | tech |
COVID-19 tracker: Tokyo cases slightly down from week before | Tokyo confirmed 4,384 new cases of COVID-19 on Monday, down by 160 from a week before as experts cautioned that another resurgence of infections may be around the corner.
The seven-day average of new cases came to 7,607.4, compared with 6,565 a week before.
The number of severe cases under the Tokyo Metropolitan Government’ s criteria fell by two from Sunday to 29, while seven new deaths linked to the virus were reported Monday.
On Sunday, Japan confirmed 47,345 new cases across the country, up about 4,000 from a week before. The daily count rose week on week for the ninth consecutive day.
Government data showed Saturday that the number of new coronavirus cases confirmed in the week through Friday increased in 44 of the country’ s 47 prefectures, less than two weeks after Japan completely lifted quasi-emergency measures.
Experts on a government panel monitoring the pandemic situation say recent rises need to be carefully monitored given a notable increase in infections among teens. The daily cases are gradually increasing apparently as the highly contagious BA.2 subvariant of the omicron strain spreads, they said. | tech |
Why Putin faces 'more NATO ' in the Arctic after Ukraine invasion | BARDUFOSS, Norway – The sound of gunfire echoed around the Norwegian fjords as a row of Swedish and Finnish soldiers, positioned prone behind banks of snow, trained rifles and missile launchers on nearby hills ready for an enemy attack.
The drill, in March, was the first time forces from Finland and Sweden have formed a combined brigade in a scheduled NATO exercise in Arctic Norway known as Cold Response. Neither country is a member of the NATO alliance. The exercise was long planned, but Russia's invasion of Ukraine on Feb. 24 added intensity to the war game.
`` We would be rather naive not to recognize that there is a threat, '' said Swedish Maj. Stefan Nordstrom. `` The security situation in the whole of Europe has changed and we have to accept that, and we have to adapt. ''
That sense of threat means Russian President Vladimir Putin, who embarked on what he calls a `` special operation '' in Ukraine partly to counter the expansion of the NATO alliance, may soon have a new NATO neighbor.
Finland has a 1,300 kilometer ( 810 mile) border with Russia. In a March 28 phone call, the country's President Sauli Niinisto asked NATO Secretary-General Jens Stoltenberg for details on principles and steps for accepting new members, he wrote on Facebook. Finland's leaders have discussed possible membership with `` almost all '' NATO's 30 members and will submit a review to parliament by mid-April, Foreign Minister Pekka Haavisto said.
Sweden — home of the founder of the Nobel Peace Prize and a country that has not fought in a war since 1814 — is more hesitant. But a recent opinion poll for a major Swedish TV station found 59% of Swedes wanted to join NATO, if Finland does.
For some in the alliance, the two countries sandwiched between Russia and NATO-member Norway are already partners. U.S. Gen. David Berger, who is the commandant of the U.S. Marines Corps, told reporters at the drill that — putting the politics of membership aside — they were brothers-in-arms during training.
`` For marines, at the tactical level … there's no difference, '' Berger said. `` I just have to know that the unit over there, they have my back. They 've got me covered. ''
Stoltenberg announced in early March that NATO was now sharing all information on the war in Ukraine with Sweden and Finland. Both countries regularly attend NATO meetings. At the exercises in Norway, Stoltenberg said `` no other countries in the world '' are closer partners.
But he noted an important difference: `` The absolute security guarantees that we provide for NATO allies, are only for NATO allies. ''
As nonmembers, Finland and Sweden's combined population of 16 million don't have the protection of NATO's guarantee that an attack on one ally is an attack on all.
Moscow did not respond to a request for comment for this story. It has repeatedly warned both countries against joining NATO. On March 12, the Russian foreign ministry said `` there will be serious military and political consequences '' if they do, according to Russian news agency Interfax.
Swedish Army armored vehicles and tanks participate in a military exercise called Cold Response 2022 in Setermoen in the Arctic Circle, Norway, on March 25. | REUTERS
Stoltenberg has said it would be possible to allow Finland and Sweden in `` quite quickly. '' NATO has not commented on what a fast-track process would be. A spokesperson for the U.S. Department of Defense said any decision would be taken by the countries themselves but their accession would need to be agreed by all 30 allies.
`` President Putin wants less NATO on Russia's borders, '' Stoltenberg said in January, also referring to more allied troops in southeastern Europe, Poland and the Baltics. `` But he is getting more NATO. ''
More than 1,000 km to the southeast of the NATO drill, 80-year-old Markku Kuusela knows real war. The pensioner, who lives in Imatra, a town on Finland's border with Russia, was evacuated to Sweden with his brother as an infant after his father was killed fighting a Russian invasion.
`` It is always in the back of my mind, '' said Kuusela, visiting the cemetery where his father is buried. Tears welled in his eyes. `` How it would have been to have a father. ''
Some 96,000 Finns, or 2.5% of the population, died fighting the Russian invasion, in two wars between 1939 and 1944. A total of 55,000 children lost fathers, and over 400,000 people lost homes as territory was conceded.
But the Finns, fighting under cover of dense forest, repelled the Russians and ever since, Finland has had a clear goal: strong defense and friendly relations with Russia.
The country built a conscript army — it has about 900,000 men and women in reserves — and according to the International Institute for Strategic Studies, one of the largest artilleries in Europe.
For years, Finns and Russians have interacted extensively. This year, Imatra was planning to celebrate a 250-year history of Finnish tourism since a visit by Catherine the Great, the Russian empress, in 1772.
Now the Imatra border station is deserted, its stalls unused. Finland's security service, known as Supo, says Russia's military resources are currently focused on Ukraine and its own domestic operations, but warns the situation may change quickly.
NATO Secretary-General Jens Stoltenberg meets Swedish troops as part of a NATO military exercise called Cold Response 2022 at a base in Bardufoss in the Arctic Circle, Norway, on March 25. | REUTERS
The Ukraine invasion triggered almost 3,000 applications from Finns to join local associations of reservists, as well as almost 1,000 to women's emergency preparedness groups, the groups said.
One applicant was Pia Lumme, a 48-year-old coordinator for the Finnish National Agency for Education who lives near Imatra. She recalled her grandmother's war memories.
`` I think we Finns all share … the will to uphold this country, '' Lumme said.
Finland is one of the few European countries to maintain a national emergency supply of fuel, food and medicine. Building emergency shelters beneath every major building has been mandatory since World War II. The country says its 54,000 shelters have room for 4.4 million of the 5.5 million population.
Finns ' backing for joining NATO has risen to record numbers over the past month, with the latest poll by public broadcaster Yle showing 62% of respondents in favor and only 16% against.
Supo, the security service, said on March 29 that Finland must guard against potential Russian retaliation to Helsinki's discussions on joining NATO, or interference in the public debate.
`` We don't need to make any quick decisions on our own defense, but certainly a possible membership application could lead to making us a target of interference or hybrid actions, '' Haavisto said in an interview. `` Finland needs to prepare for that and also listen to how NATO countries would react. ''
Sweden, which has argued that nonalignment has served its people well, has been slower to see Russia as a threat — for example, it allowed defense spending to slip and emergency shelters to fall into disrepair after the Cold War. But the mood there is also changing.
After Russia invaded Crimea in 2014, the government sped up rearmament and boosted military strength on the island of Gotland, near the headquarters of Russia's Baltic Fleet. It also reintroduced limited conscription that year.
Stockholm said earlier this month it would almost double defense spending to around 2% of gross domestic product and that it is refurbishing a network of emergency bunkers, to shelter up to 7 million people. It says there are currently around 65,000 shelters, mostly in private homes.
Around 71% of Swedes are worried about an increased military threat from Russia — up from 46% in January — according to a survey by pollsters Demoskop for the Aftonbladet daily on March 2.
Three retail chains said sales of products to prepare for emergencies had accelerated again after picking up at the start of the COVID-19 pandemic.
`` Sales of crisis kits, wind-up radios, water filters and water containers — pretty much everything — have increased, '' said Fredrik Stockhaus, founder of Criseq, a Swedish online store. Sweden's statistics office does not measure sales at this level of detail.
A member of the Norwegian army participates in a military exercise called Cold Response 2022, gathering around 30,000 troops from NATO member countries as well as Finland and Sweden, in Setermoen in the Arctic Circle, Norway, on March 25. | REUTERS
If either country does go for NATO membership, Finland looks set to move first, diplomats and politicians say. Foreign Minister Haavisto said he is in `` almost daily '' talks with his Swedish counterpart on the topic.
`` It wouldn't be ideal for Finland to go alone, because then all the risks in the application process would be on Finland, '' said Matti Pesu, a foreign policy analyst at the Finnish Institute of International Affairs.
In Sweden, the government and opposition are conducting an analysis of security policy, which is expected in May. Prime Minister Magdalena Andersson stressed on national TV on Wednesday that it was important to wait and see what conclusions that reaches. The ruling Social Democrats oppose joining, but four opposition parties support it.
Even so, Sweden's nonaligned status is increasingly blurred, said Anna Wieslander, Northern Europe Director at the Atlantic Council think tank.
`` If you look at it, we are preparing to meet the adversary together and I think there is no doubt in which camp we are, '' she said. `` You can see the warnings Russia has given so there is no doubt on their side as well. '' | tech |
Hong Kong leadership contender emerges amid uncertain future | HONG KONG – Hong Kong's deputy leader, former police officer John Lee, has signaled his intention to contest an election for the city's top job, media has reported, which could see Beijing signing off on the first security official to run the global financial hub.
Carrie Lam, the embattled incumbent leader who has seen her popularity slide, said on Monday she would not seek a second term, citing family considerations.
Hong Kong selects a leader every five years under a process that Beijing oversees behind the scenes. Since the city reverted from British to Chinese rule in 1997, there have been four chief executives, all of whom have struggled to balance the democratic aspirations of some residents with the vision of China's Communist Party leaders.
The city's 7.4 million people have no say in who leads them. City leaders are chosen in a vote by an election committee stacked with pro-Beijing loyalists, ensuring that Beijing approves the decision. In a major overhaul of Hong Kong's electoral system last year to meet Beijing's demands that only `` patriots '' run the city, this committee was enlarged from 1,200 to 1,500 members. Hong Kong's mini-constitution, the Basic Law, states that full democracy is an `` ultimate aim '' for choosing the leader.
Hong Kong’ s Chief Secretary John Lee, Chief Executive Carrie Lam and Financial Secretary Paul Chan attend a news conference in Hong Kong in March. | POOL VIA REUTERS
China's reluctance to advance democratic reforms has long been a lightning rod for the city's opposition democrats and liberal-minded citizens, stoking protest movements including the `` Umbrella Revolution '' in 2014 and pro-democracy protests in 2019.
After the recent electoral overhaul, many observers say China's promise to allow full democracy at some point in future will never be kept.
The election was initially scheduled for March but was postponed because of a COVID-19 outbreak in which more than 1 million people have been infected, putting Lam under pressure.
Unlike previous times, when likely candidates have signaled their intention to run months in advance, no clear favorite has emerged, adding to the uncertainty over the city's future.
Chief Secretary Lee is a former Hong Kong security chief and deputy police commissioner who was known as an anglophile during British colonial rule.
In recent years, he has been forceful in enacting China's harsher security regimen — with scores of democrats arrested, jailed or forced into exile, civil society groups forced to disband, and liberal media outlets raided by police and shuttered.
Other possible contenders mentioned by media include the city's financial secretary, Paul Chan, as well as former leader Leung Chun-ying. None has announced a bid.
The election is scheduled for May 8, with the new chief executive to take office on July 1. Some new chief executives have been personally sworn in by senior Chinese leaders. In 2017, the 20th anniversary of Hong Kong's return to Chinese rule, President Xi Jinping swore in Lam.
A nomination period for candidates began on Sunday and will last for two weeks, with each candidate having to secure at least 188 nominations from the 1,500-member election committee. | tech |
China's COVID-19 crisis grows with cases surging and new omicron sub-strains | China’ s COVID-19 situation is on a knife-edge, with a lockdown of its financial hub intensified amid a surge in new cases and reports of new sub-strains of the omicron variant emerging as clusters flare nationwide.
The country, which managed to live much of the pandemic effectively virus free after quashing its initial outbreak in Wuhan, is experiencing its biggest jump in daily infections since that period.
Shanghai reported 9,006 cases Sunday as the city readies to test all 25 million residents in its latest efforts to weed out infections, amid accounts of un-reported deaths in a nursing home and ongoing food shortages. The entire population is now under some form of movement restrictions.
Thousands of medical staff from around the country arrived in Shanghai on Sunday to help with the city-wide test, Xinhua News Agency reported. The People’ s Liberation Army has also mobilized more than 2,000 military medics to support Shanghai’ s virus control, according to the PLA Daily.
Businesses and some factories remain shuttered, with Tesla Inc.’ s Shanghai plant — it’ s first Gigafactory outside of the U.S. — entering a second week of disrupted operations.
Adding to concern about the situation is the emergence of what appears to be new sub-types of the highly contagious omicron strain.
A delivery worker wearing personal protective equipment ( PPE) prepares to deliver food bought online for residents who were restricted due to a recent COVID-19 outbreak in China’ s eastern Zhejiang province on Saturday. | AFP-JIJI
A COVID-19 patient in a city some 40 miles from Shanghai was diagnosed with a new iteration of the virus that evolved from the BA.1.1 branch of omicron, the state-run Global Times newspaper reported at the weekend, citing sequencing data from local health authorities. The report said the sub-type doesn’ t match other strains in China, nor those submitted to GISAID, the global database for coronavirus sequencing and monitoring mutations.
A case in Dalian city in northern China reported on Friday also didn’ t match any coronavirus found domestically, the municipal government said on its WeChat account.
With the situation spiraling, Beijing sent Vice Premier Sun Chunlan to Shanghai to oversee prevention efforts. Sun ordered local officials to curtail the outbreak “ as soon as possible, ” indicating China remains wedded to its rigid “ COVID zero ” stance despite the escalating crisis. For much of the pandemic the nation has sought to eliminate the virus, something that’ s become more challenging as the pathogen mutated to become more transmissible, evading even the toughest border curbs and quarantine regimes.
Still, in further evidence Beijing is at least planning for an eventual exit from the strategy — which has left it isolated as the rest of the world opens up — two Chinese vaccines using messenger RNA technology, or mRNA, were approved to start clinical trials. More effective vaccines are seen as key to China being able to normalize without a high number of virus deaths, political anathema to President Xi Jinping’ s government.
China is the last country in the world to still be taking such a hard line with COVID-19, after other places that pursued elimination, including Singapore, Australia and New Zealand, started to open up once vaccination reached key levels.
The experience of Hong Kong is providing a cautionary tale for mainland officials, with the city going from virus success story to the highest death rate in the world at one point. Hong Kong didn’ t lock down and mass test its population, despite Beijing’ s urgings, and cases rapidly exploded into the tens of thousands within days, triggering an unprecedented wave of death mostly among the under-vaccinated elderly community.
China’ s elderly vaccination rates are better than Hong Kong’ s, but still low by global standards, particularly among the very old. Just over half of those age 80 and older are fully vaccinated against COVID-19 in China, officials said March 18, before launching a push to get more older people to get shots. | tech |
Hong Kong leader Carrie Lam says she won’ t seek second term | Hong Kong Chief Executive Carrie Lam said she wouldn’ t seek a second term, ending a tumultuous five-year tenure that saw the financial hub become more isolated due to its twin crackdowns on COVID-19 and the democratic opposition.
Lam announced her plans at a regular news briefing Monday, saying that she informed authorities in Beijing of her plan at a National People’ s Congress session more than a year ago. Hong Kong’ s benchmark Hang Seng Index climbed as much as 2% after her announcement.
`` This is a question of my personal wish and aspiration. My personal wish and aspiration is entirely based on my family considerations, ” Lam told reporters. `` This is what I have told the central people’ s government. And they have expressed understanding. ”
Lam came under fire repeatedly during her tenure as Beijing’ s increased its control over the city: She faced U.S. sanctions over her role in helping China quash pro-democracy protests in 2019 and later drew scorn from international businesses over one of the world’ s strictest hotel quarantine policies.
The veteran bureaucrat has been the city’ s least popular chief executive since the U.K. handed control of Hong Kong to China in 1997, according to Hong Kong Public Opinion Research Institute. Her successor will take office July 1, the halfway mark in Beijing’ s 50-year pledge to preserve the city’ s liberal financial and political systems.
Would-be contenders for Lam’ s job have two weeks to step forward to compete in the May 8 vote of 1,500 mostly Beijing loyalists. Lam declined to comment on reports that her No. 2 official, John Lee, was preparing to run, saying she hadn’ t received the resignation notice that government officials must file to seek higher office.
Lee, a former top police official and security minister, had helped oversee a clampdown on the city’ s opposition after Beijing imposed a sweeping national security law in 2020.
`` It is a real concern that Hong Kong could become a police state, ” said Alfred Wu, associate professor specializing in Hong Kong politics at the National University of Singapore’ s Lee Kuan Yew School of Public Policy, saying that Lee would be the `` ideal candidate ” for that task.
`` Beijing wants Hong Kong to politically and structurally better align itself with the realities of how China operates: controlling its people through big data, and mass monitoring, ” he added.
Lam’ s term will be remembered for some of the city’ s biggest crises since returning to Chinese rule, and a further widening of divisions apparent under her former boss, ex-Chief Executive Leung Chun-ying. Leung also opted not to seek a second term amid widespread discontent.
Her proposal to introduce a law allowing criminal suspects to be sent to China sparked the city’ s largest-ever street protests in 2019. Beijing imposed the security law the following year, which has been used to jail scores of opposition leaders and shutter several pro-democracy news outlets. China also overhauled the city’ s Legislative Council to ensure only `` patriots ” who `` respect ” the Communist Party can serve.
Those curbs prompted tens of thousands of residents to leave the once-freewheeling city, while others fled stringent virus controls as Lam hewed to China’ s strict `` COVID-zero '' strategy. While that kept COVID-19 at bay for almost two years, the omicron variant broke Hong Kong’ s defenses, resulting in the city logging the developed world’ s highest death rate per capita.
The omicron wave, which some experts say infected half of Hong Kong, has served as a warning to mainland officials battling the more infectious variant in Shanghai. Before the strain arrived in Hong Kong, Lam had been tipped as the front-runner in the race, giving an interview to the South China Morning Post in November for an article that described her as a `` comeback queen. ” She had unveiled an ambitious long-term project to alleviate the city’ s chronic housing shortage.
By February, President Xi Jinping was calling on Lam’ s government to take `` all necessary measures ” to get the virus under control, in an unusually direct intervention that cast new doubt on for her political future. She subsequently invoked emergency powers to postpone the election for her job originally planned for March 27.
Last week, China’ s top leadership held a series of top level meeting to decide her fate, which resulted in her traveling Friday to the mainland city of Shenzhen, the South China Morning Post reported. Lam declined to discuss details of her communication with the central government on Monday.
Despite everything, Lam said she was handing Hong Kong’ s next leader a stronger city than the one she had inherited. Notably, she cited the national security legislation and electoral overhaul, two measures that were handed down by Beijing after years of frustration with the city’ s political gridlock.
`` Compared to this term of government, the next government will be seeing a more stable political environment, ” Lam said Monday. | tech |
China sends military and doctors to Shanghai to test all residents for COVID-19 | SHANGHAI – China has sent the military and thousands of health care workers into Shanghai to help carry out COVID-19 tests for all of its 26 million residents as cases continued to rise Monday, in one of the country’ s biggest-ever public health responses.
Some residents woke up before dawn for white-suited health care workers to swab their throats as part of nucleic acid testing at their housing compounds, many queuing up in their pajamas and standing the required 2 meters apart.
The People’ s Liberation Army ( PLA) on Sunday dispatched more than 2,000 medical personnel from across the army, navy and joint logistics support forces to Shanghai, an armed forces newspaper reported.
More than 10,000 health care workers from provinces such as Jiangsu, Zhejiang and Beijing have arrived in Shanghai, according to state media reports, which showed them arriving, suitcase-laden and masked up, by high-speed rail and aircraft.
It is China’ s largest public health response since it tackled the initial COVID-19 outbreak in Wuhan, where the coronavirus was first discovered in late 2019. The State Council said the PLA dispatched more than 4,000 medical personnel to the province of Hubei, where Wuhan is located, at that time.
Shanghai, which began a two-stage lockdown on March 28 that has been expanded to confine practically all residents to their homes, reported 8,581 asymptomatic COVID-19 cases and 425 symptomatic COVID-19 cases for April 3. It also asked residents to self-test on Sunday.
Although the outbreak is small by global standards, the city has emerged as a test of China’ s elimination strategy based on testing, tracing and quarantining all positive cases and their close contacts.
The exercise in China’ s most populous city takes place on the eve of when Shanghai initially said it planned to lift the city’ s lockdown.
The country has 12,400 institutions capable of processing tests from as many as 900 million people a day, a senior Chinese health official was reported as saying last month.
China primarily uses pool testing, a process in which up to 20 swab samples are mixed together for more rapid processing.
The city has also converted multiple hospitals, gymnasiums, apartment blocks and other venues into central quarantine sites, including the Shanghai New International Expo Center, which can hold 15,000 patients at full capacity.
The surge in state support for Shanghai comes as the city is straining under the demands of the country’ s “ dynamic clearance ” strategy, with residents complaining of crowded and unsanitary central quarantine centers, as well as difficulties in securing food and essential medical help.
Some have begun to question the policies, asking why children with COVID-19 are separated from their parents and why mild or asymptomatic infections — the majority of Shanghai’ s cases — can not isolate at home.
On Monday, Shanghai official Wu Qianyu told a news conference that children could be accompanied by their parents if the parents were also infected, but separated if they were not, adding that policies are still being refined.
Shanghai has emerged as a test of China’ s elimination strategy based on testing, tracing and quarantining all positive cases and their close contacts. | BLOOMBERG
A Shanghai resident, who declined to be named for privacy reasons, said he had been transported to a central quarantine facility on Sunday night after reporting a positive result from a self-test more than a week ago.
Another antigen test on Saturday showed he was no longer infected, but authorities insisted on sending him to quarantine, where he has been put in a one-bedroom flat with two other patients, both of whom are still testing positive.
“ How is this isolation? ” he said, adding that he was now afraid of being reinfected. “ I’ m not in any mood to do anything right now, I can’ t sleep. ”
The pressure on the city’ s health care workers and Communist Party members has also been great, as they are working around the clock to manage the city’ s lockdown and deal with residents’ frustrations.
Photos and videos have gone viral on Chinese social media of exhausted workers and volunteers sleeping in plastic chairs or on the grass outside housing compounds, or being berated by residents.
On Saturday, the city’ s Pudong Chinese Center for Disease Control said it was investigating a leaked recording of a call between a staff member and the relative of a patient, who was perplexed by his father’ s COVID-19 test results.
The CDC staff member, who local media identified as an infectious disease expert, could be heard saying exasperatedly that she herself had raised concerns over the current quarantine and testing rules. Reuters was not able to independently verify the recording.
Chinese President Xi Jinping has urged the country to curb the momentum of the outbreak as soon as possible while sticking to the dynamic clearance policy.
On Saturday, Vice Premier Sun Chunlan, who was sent to Shanghai by the central government, urged the city to “ make resolute and swift moves ” to curb the pandemic.
The eastern city of Suzhou said it has detected a version of the omicron BA.1.1 subvariant that doesn’ t match any others in the domestic database or the international variant tracking database GISAID, state television reported.
The state-backed Science and Technology Daily said it remains unclear whether the virus is a new sub-branch of omicron and that the emergence of one or two new versions is normal given the spread of omicron in China, citing an unidentified expert with a national database. | tech |
Senators reach $ 10 billion Covid funding deal for therapeutics, vaccines and testing | Senate Republicans and Democrats reached a deal Monday on $ 10 billion in additional Covid funding to buy therapeutics and vaccines and maintain the nation's testing capacity if another Covid wave hits the U.S.
The legislation earmarks at least $ 5 billion to purchase and develop Covid treatments such as antiviral pills. Another $ 750 million is set aside to develop vaccines that target specific variants and to expand vaccine manufacturing capacity in the U.S. if needed.
The funding is less than half the $ 22.5 billion that President Joe Biden first requested. The deal does not include money to support the administration's efforts to increase vaccinations around the world.
White House press secretary Jen Psaki said every dollar the administration requested is essential, and noted that the White House will work to get Congress to pass more aid. However, Psaki said time is of the essence, and urged lawmakers to swiftly pass the $ 10 billion.
`` We urge Congress to move promptly on this $ 10 billion package because it can begin to fund the most immediate needs, as we currently run the risk of not having some critical tools like treatments and tests starting in May and June, '' Psaki said.
Congress has fumbled Covid funding as the White House warned that the U.S. would not have enough money to ensure all Americans have access to vaccines in the fall without new aid. House Democrats originally sought to pass $ 15 billion in Covid funding last month, but Republicans insisted on redirecting money already appropriated for state and local governments to cover any new spending. Negotiations moved to the Senate after the House failed to reach a bipartisan agreement.
Sen. Mitt Romney, R-Utah, said the $ 10 billion is fully paid for by repurposing unspent Covid funds from the Agriculture, Education, Treasury and Transportation Departments as well as the Small Business Administration.
Senate Majority Leader Chuck Schumer, D-N.Y., said he was disappointed the legislation does not include money to support the Biden administration's efforts to increase vaccinations around the world. Schumer said the initiative is crucial to prevent the emergence of a breakthrough Covid variant that can evade the protection provided by the current shots.
Schumer and Romney said they were willing to work together on a supplemental international Covid aid package later this spring.
Read CNBC's latest global coverage of the Covid pandemic: | business |
Insurance market hardening slows down, but concerns remain | BI’ s Article search uses Boolean search capabilities. If you are not familiar with these principles, here are some quick tips.
To search specifically for more than one word, put the search term in quotation marks. For example, “ workers compensation ”. This will limit your search to that combination of words.
To search for a combination of terms, use quotations and the & symbol. For example, “ hurricane ” & “ loss ”.
A survey by U.K.-based Association of Insurance and Risk Managers in Industry and Commerce showed that 44% of respondents are still concerned about insurance market conditions although market hardening has slowed down since late 2021, Captive Insurance Times reported. While talking in the context of a post-Brexit, post-COVID 19 pandemic London insurance market, the respondents highlighted increased coverage exclusions, reduced insurer capacity and slow but considerable rate hikes as some of the characteristics now more prominent during insurance renewals.
1. Regulator revokes licenses of financially troubled insurers
2. Axa won’ t appeal landmark COVID-19 BI ruling
3. Brokers calls for mandatory insurance for all buildings
4. Hardening market to go on longer than anticipated: Howden
5. Insurers settle $ 20.5 million claims related to plane crash
6. Insurance market hardening slows down, but concerns remain | general |
Judge says Pop-Tarts consumers likely not in it for their health | BI’ s Article search uses Boolean search capabilities. If you are not familiar with these principles, here are some quick tips.
To search specifically for more than one word, put the search term in quotation marks. For example, “ workers compensation ”. This will limit your search to that combination of words.
To search for a combination of terms, use quotations and the & symbol. For example, “ hurricane ” & “ loss ”.
A federal judge in Manhattan on Thursday wasn’ t buying it.
In dismissing a proposed class-action lawsuit accusing Kellogg Co. of misleading health-conscious customers in its labeling of Frosted Strawberry Pop-Tarts, the judge said reasonable shoppers would not expect strawberries to be the main ingredient in a `` pre-packaged, processed sugary treat called Frosted Strawberry Pop-Tarts, '' according to Reuters.
The judge also rejected the idea that Pop-Tarts buyers missed out on the health benefits of strawberries.
`` A reasonable consumer is unlikely to purchase a toaster pastry coated in frosting exclusively for the nutritional value of strawberries in its fruit filling, '' he wrote.
Last month, a federal judge in Chicago dismissed a similar lawsuit over unfrosted Strawberry Pop-Tarts, saying Kellogg did not guarantee how many strawberries it would use.
A U.S. securities regulator could now ask of Elon Musk: Will the fake Slim Shady, please shut up?
1. Lockton recruits cyber leader from AIG
2. Munich Re tightens up cyber insurance policies to exclude war
3. Lakers can proceed with COVID property case against Chubb unit
4. Commercial prices continue to increase in Q1: MarketScout
5. Navigators adds former Everest wholesale property exec
6. Burger King accused of whopper of a lie | general |
Pete the Vet: Can I give my dog Covid? - and other pet questions | Pete the Vet: be careful about feeding your Bernese mountain dog puppy too many scraps from the table.
We have a Golden Retriever, she’ s young, she’ ll be one this summer. Our garden is destroyed! How do I stop her pee from rotting our grass? Can I adjust her diet, avoiding or adding any particular foods?
- Nicola, Cork
The brown patches on grass lawns caused by dog urine are due to the fact that urine is high in nitrogen. While small amounts of nitrogen make grass grow quicker, too much is toxic, killing the grass. This is why it’ s common to see dead, yellow patches of grass surrounded by lush green rings at the edges. There are numerous unproven methods that claim to solve this, from giving a dollop of tomato ketchup in the food every day, to proprietary “ rocks ” that you put in the dog’ s water bowl.
My own view is that if you can’ t prevent your dog from urinating on the grass in the first place, the best answer to pollution is “ dilution ”. Keep a bucket of water handy, and if you see your dog piddling on the lawn, drench the area in fresh water.
We all have Covid in the house. My son is worried about petting our dog because he says he might make him sick. Can we give our dog Covid?
- Rosie, Cork
Globally, there have been a tiny number of isolated cases of dogs in Covid positive households becoming unwell and testing positive for Covid. The chance of this happening to your dog is very slim indeed. I would tell your son not to worry about petting your dog: the benefits of companionship for the two of them far outweigh the tiny disease risk.
However, when people are at the peak of infectivity ( i.e. sick in bed with a high temperature), it makes sense to reduce contact with everyone, people and animals alike. This is a common-sense way of minimising the possible spread of any disease, even when the risk is already very low.
We recently got a new puppy, a Bernese Mountain Dog. At what age can I feed him some leftover food from the table?
- Norma, Cork city
You can add a very small amount of scraps to his diet from an early age but you need to be careful. As a giant breed of dog, it’ s important that you feed your puppy a diet that is nutritionally balanced, to encourage strong, even growth of bones, muscles and other tissues. Most nutrition-related diseases happen when people put together food for their pets by themselves, rather than using balanced diets prepared by professional veterinary nutritionists.
It’ s surprisingly difficult to create a balanced diet by guesswork. Assuming you are feeding him on a complete, dry, diet, designed for large breed puppies, he really doesn’ t need anything else at all. While it’ s generally safe to add around 10% of the total food intake as leftovers from the table, it’ s better not to give any more than this quantity. | general |
Clear communication, training can head off angry customers | A customer at a southwest Michigan dealership demanded a loaner while her vehicle was being serviced. When told no because she didn't have auto insurance, the customer locked herself in her vehicle in the service lane. She only left after police showed up.
The owner of a new Mitsubishi Eclipse brought the vehicle to the South Carolina dealership service department citing several mechanical issues. When technicians couldn't replicate any of the problems, the customer wanted the dealership to buy the vehicle back. When the customer was refused, he returned with a sign declaring the dealership a rip-off. Police were called, and the man left.
A customer at a New England dealership didn't like the pricing for parts and labor. He brought used components from salvage yards to the dealership and demanded techs there give him their tools so he could do the repairs himself. Police were called to escort the customer off the premises.
The past few years have seen an uptick in angry customers in grocery stores, fast-food restaurants — even public parks. And, as evidenced by the stories above, dealership service departments have not been immune.
No one can quite pinpoint the source of the anger. Two years of lockdowns and COVID-19 rules? A lack of parts causing longer repair times? Rising prices for maintenance and repair work?
A service director at the multibrand dealership in southwest Michigan who requested anonymity says the root cause of the surging number of surly customers is a growing sense of entitlement.
`` People are demanding more than you can provide and get upset when you can't meet their needs, '' he says. `` It seems like they believe that if they're mean enough to the employee, they 'll get what they want. They seem fed up with everything, and they're taking it out on the next person. ''
If he senses a customer getting frustrated with what a service adviser is telling them, he 'll invite both into his office to remove the tension from front-line staff and other guests and to let the customer vent.
But he says a result of service advisers being on the dealership front lines and sometimes the bearer of bad news is they are leaving for other jobs rather than enduring more abuse. | general |
As the pandemic drags on, more in Japan find solace in 'oshikatsu ' devotion | “ Oshikatsu, ” a Japanese word meaning the act of enthusiastically supporting someone like an idol singer or actor that one feels particular devotion to, is increasingly taking hold in Japan.
Such activities — long monopolized by otaku, or people with an obsessive interest in Japanese pop culture such as anime and manga — have now become a part of everyday life for many people, with such fans increasingly interacting via Instagram and Twitter.
With the COVID-19 pandemic having gone on for more than two years, they are putting even more energy into oshikatsu, which gives them opportunities to think positively again and broaden their mind.
“ I can’ t go back to life without it, ” says Yukiko Fukuda, a 49-year-old resident of Hiroshima’ s Saeki Ward whose “ oshi ” — a person or a thing you support — is South Korean boy band BTS.
After being thrilled by their performance on TV a little more than a year ago, she found herself browsing more and more related websites and then started buying BTS merchandise. She even held a birthday party for one of the members, alone at home with a specially prepared macaron. “ There are countless ways to enjoy yourself, ” she says with a smile.
Oshikatsu is also expanding among fans of athletes and YouTubers.
Hiroko Sebu, who works as a composer, became a fan of baseball player Ryuji Yokoyama about 10 years ago when he captured her attention while pitching as a member of the Hiroshima Carp, at Mazda Stadium in Hiroshima’ s Minami Ward. Since then, she became an enthusiastic Carp fan and the COVID-19 pandemic prompted her to move from Tokyo to Hiroshima in July to live near the stadium, the team’ s home ground.
Yumi Watanuki, 27, of Minami Ward, supports an actor performing in so-called 2.5-dimensional stage productions ( 2.5D) that draw on manga, anime and computer-game content.
Watanuki became a fan of the actor when she had been having difficulty deciding what to do after graduating from college, and this led her to choose to work for an entertainment agency.
Writer Yoshiaki Yokogawa, 38, published a book with a title that translates roughly to “ I, an otaku of handsome actors, seriously thought about what oshi means to mankind. ” He explains that oshi is a shortened form of oshimen — in turn an abbreviation of “ oshitai menbā, ” meaning “ a ( group) member you want to support. ”
The word began to be recognized widely in around 2010 along with the rising popularity of idol girl group AKB48, according to Yokogawa.
Novelist Rin Usami last year won the prestigious Akutagawa Prize literary award for her novel “ Oshi, Moyu, ” which translates as “ Oshi on fire. ” The novel attracted attention as it depicts a high school girl’ s life falling apart after a male idol she follows becomes involved in a scandal.
While otaku who are obsessed with anime and idols tended to attract a negative impression in the past, Yokogawa says people began to have a positive image of them amid increased diversity of thought.
Moreover, with vast amounts of information available on the internet, it has become easier for people to find content about the subjects of interest. Online communities of devotees expanded, further boosting the phenomenon.
People who are too obsessed with oshikatsu are described as “ falling into a swamp. ” And the swamp can sometimes turn out to be bottomless.
Sachiko Takeuchi, a 39-year-old manga artist, fell into a swamp following the 2011 Great East Japan Earthquake. She would often be gone from home for a week at a time to watch performances by 2.5D actors, and would spend any amount of money to buy presents for them.
The oshikatsu-centered lifestyle damaged her health and seriously affected her household finances.
In a manga essay with a title that translates to “ I’ m turning 40 in a swamp, ” she writes about how her fear over the 2011 disaster triggered the situation.
Environments in which people are forced to work remotely or refrain from going out can also make them prone to becoming overly obsessed. The internet is overflowing with content related to oshi, and people can access them limitlessly while at home; this is the joy of oshikatsu.
But, Takeuchi said, “ It is dangerous to try to ease your fear and stress by devoting yourself to oshikatsu. ”
There are no clear rules to oshikatsu. “ You have to discipline yourself, such as setting a time limit ” in order to avoid becoming addicted, Takeuchi said.
Jane Su, a 48-year-old novelist and columnist, described her own oshikatsu rules in her book “ Hitomazu Jodeki, ” which roughly translates to “ Well done for now, ” creating a buzz online and striking a chord with many people involved in oshikatsu.
Her rules are to never disclose who she supports, and never mention her oshi on radio nor in magazines.
The degree of enthusiasm for oshi differs by people, so any remark or act could lead to conflicts even with others who support the same individual.
Su says if fans respect each other and think about how the person they support is also special to someone else, they can engage in the kind of activities that fit them without being overly influenced by others.
Su’ s essay, filled with love for oshikatsu, says, “ Everyone lives with something heavy on their heart to a greater or lesser extent. Only you yourself can lift up your heart, but I don’ t get motivated to do so without the help of oshi or entertainment. ”
You can be energized if you cheer for someone you are a great fan of, to your heart’ s content, in a place outside home or work. The oshikatsu fever is likely to continue for some time to help people live positively and survive tough times.
This section features topics and issues covered by the Chugoku Shimbun, the largest newspaper in the Chugoku region. The original article was published March 9. | tech |
Drone footage shows deserted Shanghai as city remains in lockdown – video | Covid-19 cases in China’ s most populous city of Shanghai have risen again as millions remain isolated at home under a sweeping lockdown. Drone footage shows the usually bustling city empty of people and traffic. Almost all 26 million residents are under some form of lockdown. Those who test positive are taken to large quarantine centres. Jane Polubotko, a 30-year-old who works for a local music tech company, was taken to the Shanghai New International Expo Center after testing positive. 'We get food three times a day, the food is OK, ' she said. 'There are no showers here and we're not allowed to receive any parcels from the outside world '
Source: Reuters
Mon 4 Apr 2022 06.39 BST Last modified on Mon 4 Apr 2022 09.02 BST | general |
Y Combinator's Winter 2022 Cybersecurity, Privacy, and Trust Startups | Y Combinator hosted its Winter 2022 Demo Day last week from March 29-20. This batch included the largest number of cybersecurity, privacy, and trust companies in the history of Y Combinator.
Agency: Managed security and privacy for individuals and growing companies.
Bunkyr: Account recovery without seed phrases or backup codes.
Cinder: Operating system for trust and safety.
Firezone: Open-source alternative to corporate VPNs.
JumpWire: Data security for every API and database.
Netmaker: Automated WireGuard networks for distributed systems and Kubernetes.
Palitronica: Solutions to defend critical infrastructure and key resources.
Reality Defender: Enterprise deepfake detection.
Rownd: Instant user accounts and authentication.
Sarus: Protect access to personal data for analytics or machine learning.
Strac: Safely exchange sensitive data with customers and partners.
Vista: Enable role-based access across customer groups.
This article takes a deeper look at all 12 companies, their opportunities, and their challenges going forward. Twelve companies is a lot for one batch — nearly twice as many as the seven companies I covered in the S21 batch ( a nostalgic article, too — the first one I ever wrote on this site).
Unsurprisingly, this is a long article. Each company is a standalone section, so feel free to skip around or read about the ones you're most interested in. There is some cross-referencing between similar companies, but the commentary about each company generally makes sense on its own.
`` Agency performs enterprise-level cybersecurity for individuals at the highest risk of cyberattacks because of their job, employer, or industry. ''
In tangible terms, they provide a managed bundle of products and services for cybersecurity and privacy. For security-focused people like us, the bundle is excellent: antivirus/EDR, password manager, dark web monitoring, personal information removal, cyber insurance, and security monitoring services.
Agency provides many of the services that companies get from Managed Detection and Response ( MDR) and Managed Security Services Provider ( MSSP) services, but for individuals and growing companies.
Agency is bundling multiple parts of the cybersecurity ecosystem. They provide a productized service for individuals and smaller companies. Their offering maps to:
The unique twist is that these area of the cybersecurity ecosystem are historically enterprise-grade products and services. Making them accessible to individuals and small companies is incredibly appealing. I expect they 'll continue adding more products and services to the bundle over time to make the value even more compelling than it already is.
Inertia is likely the biggest challenge Agency faces today. Average consumers either don't know they should have a bundle like Agency, or they aren't willing to pay $ 20+/month ( $ 240+ annually) for it.
People earlier on the adoption curve ( people like you, if you're reading this) understand the importance of security at both an individual and company level — and have the means to pay for it. As we learned when exploring 1Password's adoption curve, the consumer and B2B market of early adopters ( enthusiasts and visionairies) is more than enough to build a large company.
Preferences and switching costs are also a potential challenge. Some people already have parts of the bundle and may not want to give up the services they're already using. Agency has a growing list of partnerships, though ( 1Password is included as part of the subscription, for example). I don't see this duplication of services as a major challenge. The value of the bundle is still incredible, even with some duplication.
Finally — and perhaps more of an opportunity than a challenge — Agency needs to crack the code on enterprise sales and get companies to provide Agency to employees as a perk. We already know enterprises can be a great channel ( Calm for Business, as one example). Companies buying Agency for employees is a clear win-win: a great perk to provide, and a nice growth channel for Agency.
Agency is a useful solution to a tough problem in a sneaky large market. The `` individuals at the highest risk of cyberattacks '' part of their company description is a lot bigger than you might think.
In the past year alone, we 've had journalists targeted by nation-states, a billionaire hacking experiment, and more. I would definitely put people like you and me in that classification as well.
Agency is one of my favorite companies from this batch. I backed that statement up with my money — I like this company so much that I bought a plan for myself. You should, too ( they're not paying me to say that).
Getting all these services for $ 20 month ( with an individual plan) feels like I 'm getting far more value than I 'm paying for. It's a `` how do they give me all of this profitably? '' type of reaction, in the best possible way. I have wanted a service like this for a long time, and I 'm excited it's finally here.
Strategically, what they're doing is right in line with my previous thoughts on bundling and blue ocean strategies. They're building a new type of business model and using scale to provide differentiated value to a new-ish type of customer. As we 've seen with 1Password and a handful of other companies in cybersecurity, that's a recipe for success.
Bunkyr is a full-blown account recovery platform delivered to developers through an API. For security-focused products, the traditional approach is to issue recovery keys when accounts get created. Users are responsible for storing them…somewhere.
Bunkyr addresses the nebulous somewhere issue by providing a white-label service developers can integrate into their apps. It gives users an account recovery workflow to securely recover their accounts ( and data, more importantly) without the need to store recovery keys or follow any less secure processes.
I would broadly map Bunkyr into a combination of Access Control and Encryption. They're creating a new category by breaking off a specific ( and gnarly) piece of authentication and authorization.
As the saying goes, old habits die hard. Making developers aware a solution like Bunkyr exists and convincing them to use it instead of plain ol ' recovery tokens is a challenge the company will have to solve.
Some products ( and the developers who build them) don't value account recovery highly enough to seek out an advanced solution like Bunkyr. We're still teaching developers not to roll their own auth:
If not, why are you building auth for your app? https: //t.co/7HC5rmJBG4
…let alone not building a seemingly obscure feature like account recovery tokens and workflows.
That said, there are likely enough ( and increasingly more) companies and products who do care about account recovery — the new generation of user-friendly cryptocurrency wallets, for example. No company was going to solve this problem on their own, but there are plenty who would be happy to use Bunkyr as a simple API integration once they know about the product.
Account recovery might seem like an obscure problem until you realize that 20% of minted Bitcoin — roughly $ 172 billion (!!!) at today's BTC price — has been lost forever, largely due to this exact problem. And Bitcoin is just one of many instances of the problem.
Companies could build their own account recovery solutions, as they have in the past with account recovery keys. But there's no point. Just plug into Bunkyr's API, and the problem is solved.
Advanced security is becoming both an important feature and a central part of the value proposition for an entire class of new products. Bunkyr could be the right solution at the right time for this problem domain.
Cinder is a platform that powers trust and safety teams — typically companies with social products or user-generated content. It's a purpose-built set of workflows that helps these teams manage reviews and decisions for abusive content, fraud, and threats in their platforms.
Cinder is interesting because it's purely a trust and safety platform, not a cybersecurity platform. I 'm broadening the traditional definition of cybersecurity and privacy to include trust and safety as a topic within the ecosystem; however, it's a different set of users and buyers within a company.
My original cybersecurity ecosystem mapping didn't include trust and safety, content moderation, censorship, or any related topics. In hindsight, this feels like an omission. I 'm planning to fix it in the next version.
Finding customers at the right level of traction and scale to require more advanced trust and safety operations is potentially tricky. Small companies with seed funding or earlier are usually still seeking traction. This doesn't leave much room to focus on problems outside of growth — trust and safety being one such problem.
There is also a lot of variety in this space. Trust and safety threats and problems vary by company and by industry, as do the processes for solving them. Cinder offers customizable workflows for this exact reason, but managing the variety is a potentially difficult product management challenge.
Problems with abusive content, fraud, and threats were a nascent problem that only existed in the world of large social media companies. Or so we thought. We 've now entered an era of misinformation, abuse, and outright information warfare that causes massive societal problems and elevates the discussion about trust and safety into the public spotlight.
Large social media companies like Facebook ( where Cinder's founders came from) and Twitter already have dedicated trust and safety teams. The problems in this domain are far from solved, but these companies are leading the way forward. For companies who aren't at the scale of Facebook or Twitter yet, the problems of trust and safety remain somewhat nascent and unaddressed.
Unfortunately, some of the most pressing problems in privacy, censorship, and content moderation can only be solved by large tech companies like Facebook and Twitter. They have large, specialized teams of their own and don't need to spend much time looking externally for solutions, even if they should.
A potential exception is qualified people from large tech companies ( with an understanding of the problems they face) who leave and build a company. Without good regulation to guide the market, the people with the best chance of creating a positive impact are likely the ones who understand the problems and nuances from the inside.
That's exactly what happened with the co-founders of Cinder. Qualified people from Facebook's trust and safety team left to build a company. They understand the problems and nuances from the inside, which means they can productize and help teach everyone else the leading practices for trust and safety. This gives Cinder a huge advantage in winning this market.
Firezone is an open source Virtual Private Network ( VPN) server and firewall. It's built on Wireguard, a shiny new VPN protocol that's faster and more secure than the old school ones your company is probably using today ( especially if you work in an enterprise).
Firezone fits quite nicely into the Virtual Private Networks ( VPN) segment of the cybersecurity ecosystem.
One slight nuance is that Fireguard is meant for teams and includes lots of business-focused features. This differs from consumer-focused VPNs like NordVPN or ProtonVPN. The concept of a VPN is the same for both consumers and businesses, but the products and management features differ depending on the type of customer.
The market for VPNs is mature and crowded. In the internet era, VPNs are as old as time. There are a lot of companies who make VPN software ( over 200, according to a quick search on company data). In crowded markets, standing out from competitors is hard.
Inertia could play a factor in their success. Most businesses already have VPNs, and some are going to be content with `` good enough '' speed and security — or barely consider it at all. In cases like this, getting companies to switch usually requires an exponentially better product or another significant differentiator to break the inertia.
There is a ( surprising?) amount of innovation in network architecture. Emerging paradigms like, Zero Trust, Secure Access Service Edge ( SASE), and software-defined perimeter ( SDP) aim to replace VPNs with more granular levels of control. These trends are still being sorted out, and companies are early in the adoption cycle. However, if the trends catch on, the role of VPNs could be diminished.
Finally, WireGuard is an open source protocol. That means anyone can build a VPN product on top of it, as many companies have. Plenty of companies have done well at building from open source software ( YC's own GitLab is one great example), so it can definitely be done — it's just an additional challenge to overcome.
The COVID-19 pandemic essentially made every company a remote company. If companies didn't have a VPN before March 2020, or if their existing VPN was too slow, insecure, or scaled poorly, they were in trouble.
Two years later, it's clear that remote and hybrid work are going to stick around in some shape or form, even as the pandemic subsides. This mega-trend elevates the priority of VPNs significantly — they're basically mission critical now.
If Firezone can build an awesome product with blazing fast speed and exceptional security, companies will adopt it. As a startup, they can also move fast and expand their products to address emerging network architecture trends and become the de facto open source company for everything related to network access.
JumpWire protects sensitive data in applications and APIs. The product proxies requests from users and applications to dynamically ( and virtually) encrypt sensitive data fields. This overview diagram is super helpful:
Instead of using database-level encryption to encrypt specific fields ( or entire tables or databases) in a database, JumpWire does the encryption on the fly. It also helps customers find their sensitive data in the first place.
I would generally classify JumpWire into Database Security and API Security. The product is also similar to a few products within the Privacy By Design category, which includes data anonymization and developer-focused privacy tools.
Adoption, by far. Changing developer behavior is hard. In Observations About the Cybersecurity Ecosystem in 2021, I said this about developer adoption for privacy-focused developer tools:
Privacy-focused developer tools and the concept of Privacy By Design have a better chance of adoption in the near-term. As discussed earlier, DevSecOps is gaining traction quickly. Privacy-focused dev tools are very closely related and are already making their way into the workflows of forward thinking dev teams.
There are lots of emerging solutions in this space, so it's a race to become the de facto approach and tool for solving the problem of data security.
All of the technical challenges are minor — they're implementation details that are easily overcome. Adoption is a tricker problem to solve.
JumpWire is a nice solution for a converging set of problems and opportunities. Data loss/leakage is a serious problem, as demonstrated by many recent data breaches. Privacy regulations add a layer of obligation and concequence on top of this. Security-minded developers are also becoming more aware of the need to protect the data their applications consume.
There definitely isn't a `` one best way '' to implement field-level data security yet. Products like Skyflow take the approach of securing your data in their own vault and exposing it via API. JumpWire essentially takes the opposite approach and inserts the product in front of any API or database you want to use.
JumpWire could become the go-to option if they gain favor with developers and build a product that makes it easy and fast for them to do the right thing with their sensitive data.
Netmaker is an open source virtual networking platform for building networks between distributed systems. It's built on Wireguard, which makes the connection speed faster than other secure networking protocols.
The company gives a helpful mental model to describe what they do: `` Think of Netmaker like your VPC for distributed systems. ''
If Netmaker sounds familiar to Firezone, you're right on track. Netmaker and Firezone are both VPNs built on the Wireguard protocol. The difference is that Netmaker is focused on building secure virtual connections between cloud networks and workloads, while Firezone is focused on business users and endpoints.
Netmaker could technically be classified as a Virtual Private Networks ( VPN); however, it's more accurate to map the company under Secure Networking.
Similar to Firezone, there are a lot of product and protocol options for businesses to set up secure network connections. A lot of them are slow, hard to configure, and generally a pain — but they eventually work.
Netmaker needs to gain traction with infrastructure engineers, SREs, and similar people who care deeply about the nuanced problems of network engineering and security. The GitHub repo for their open source project has 3.5k starts — clearly evidence of initial traction with their users.
Netmaker's real value is simplifying multi-cloud network connections and making them more performant. Early stage companies are usually able to keep their infrastructure within a single cloud, but growing startups and enterprises quickly run into this set of multi-cloud problems. It's a larger market than you might think.
Unlike consumer VPNs, the rise of remote work isn't a driver here. However, continued ( and exponential) adoption of cloud computing is. Netmaker will be successful if it becomes the de facto option for building secure network connections in distributed cloud systems.
Palitronica builds products that protect criticial infrastructure ( Operational Technology, or OT) and hardware supply chain components from cybersecurity attacks.
The company currently makes two products, Palisade and Anvil, that protect devices at runtime and provide hardware assurance over manufactured devices and semiconductors.
OT security came into focus in 2021 with the high profile Colonial Pipeline ransomware attack. Hardware security has been, and continues to be, a glaring area of concern for many companies and nation-states. Palitronica is stepping in to help protect these important physical assets.
Palitronica is part of the Physical Security domain of cybersecurity. Their current products map closely to Operational Technology ( OT) Security.
Hardware security is an advanced domain within cybersecurity, which can unfortunately make products like Palitronica hard to understand for many cybersecurity professionals. Awareness is definitely a challenge, but it only matters that the people who are truly buyers understand what the product does and the value it brings.
Many of Palitronica's early customers are government agencies, which are notoriously slow moving and technology averse. Long sales cycles and slow adoption are an inherent challenge of working with the public sector. However, they 've already demonstrated several nice wins for an early stage company.
Palitronica feels like it has a Palantir-esque mystique — a company with advanced technology solving an important societal problem. Even if hardware security isn't well understood by most people in the world, it's still a serious problem that has a high probability of getting worse.
The company is founded by domain experts with decades of experience in academic research around embedded systems at the University of Waterloo. It's a competent team who understands how to solve the difficult problems the industry faces.
Palitronica is the type of company that can be more than just big if their product truly is a significant advancement that gains adoption by governments and device manufacturers.
Reality Defender is a platform that helps companies, governments, and journalists detect fake media content ( aka deepfakes). The company originated as a project incubated by Microsoft and the AI Foundation. It's now a standalone company with products that make deepfake scanning available via a web interface and API.
Deepfake detection is an emerging subcategory within Artificial Intelligence that I didn't include in my original cybersecurity ecosystem mapping. This should be included in a future version as companies are now starting to emerge with products to help address the problem.
People are skeptical, if not outright terrified, of deepfake detection technologies because of how their models are trained ( and numerous other ethical issues around AI in general). The discussion around Reality Defender's Hacker News launch was long, spirited, and sometimes unpleasant.
Deepfake detection can theoretically improve the quality of deepfakes if bad actors treat it like a game.
Retrospective, pattern-based techniques for deepfake detection are inherently always behind the latest and greatest deepfake generation techniques. It's a cat-and-mouse game.
AI models used for deepfake detection are only as good as the datasets used to train them. Unfortunately, many of those datasets contain inadvertent ( or explicit) bias — especially towards gender and ethnicity — which subsequently bias the results of the model.
Even if the tech works reliably, users can still misuse it if their intentions are questionable.
These challenges ( and more) are all very real, but combatting deepfakes is also an important problem. Reality Defender feels like a team who can make significant advancements towards addressing them.
The problems created by deepfakes — and fake content in general — are getting exponentially worse ( in volume) and more complex to combat. It's hard to overstate the potential magnitude of this set of challenges.
As with computer viruses, deepfakes will continue evolving to circumvent current security measures. New deepfake detection techniques must be as iterative as the generation methods.
Put differently ( my words, not theirs), deepfakes are like viruses for the human mind. Psychological operations are bad — basically at a level of bad that can disrupt the stability of entire nation-states and international relations. We need the best possible tech humankind can invent to counter these types of attacks.
On a more down-to-earth and practical basis, deepfakes are behind a lot of the fraud that occurs within the financial system. Unsurprisingly, many of Reality Defender's early customers are financial institutions.
Reality Defender is in a good position because they have very tangible, quantifiable, and important problems that can be addressed right away ( things like fraud) while they continue to make progress towards massive global issues like psyops and information warfare.
Rownd helps companies onboard new users faster and keep them authenticated across multiple sites. It replaces an application's back end user store or third party authentication platforms like Auth0.
Developers can use the product by embedding a code snippet, then decide how deep they want to take the integration from there. The product is mostly white-label and ranges from a visible component for sign-in to full integration with your own form code.
In more technical terms, Rownd proactively onboards users by creating anonymous accounts for any visitor to your site. They create an `` unclaimed '' account for the user and enrich it with additional information, if available ( e.g. from a newsletter, CRM, or other service).
Once the user decides to register, they simply claim the account that was already there for them and use it for continued authentication and authorization as they use the product. Think of it like proactive onboarding.
Rownd is technically an authentication product; however, that classification is nuanced. TL; DR: it's more of an onboarding product that happens to do authentication.
We create accounts that span apps and websites – and we happen protect them.
We want to kill the login page. We want first time users to be able to enjoy an app or website first and then, when they fall in love with the product, then you ask for validation/authentication.
Authentication is more of a check box for us, what you do with the data is our product.
Rownd's current challenge seems to be helping potential users quickly understand what the product does and why it's valuable. One of the main themes of the discussion from their Hacker News launch was people trying to figure out those exact questions.
I 'm a good case study: I know a lot about identity and access management ( and have written about it several times here), and it still took me ~15 minutes to finally understand what Rownd is doing and how it works. Most potential customers aren't going to spare them that much time.
Part of this challenge ( and opportunity, perhaps) is that static login pages are such an entrenched paradigm of internet use that they're part of everyone's mental model about onboarding. Killing the static login page breaks this mental model, and people are left wondering what would replace it.
Belaboring this point is being nit-picky — Rownd will figure out its marketing. They already made several updates quickly based on HN feedback, so props to them for learning and moving fast. This probably isn't a long term challenge.
Bigger picture, the authentication market is brutally competitive, as I 've said many times before. There are well-established companies that are already public, a set of late-stage startups ready to IPO, and another set of well-funded early stage startups. This competition is great for customers because it creates innovation, but it's hard for individual companies who may or may not win the market.
The path to becoming a large company in this market is somewhat established already. Auth0 did it, and companies like Transmit Security aren't far behind. No company's path is ever the same, but we have an idea about what it takes to be successful here.
Rownd's growth trajectory and TAM is similar to other high growth passwordless authentication companies — they need to gain developer adoption, attract other high growth companies as customers, and increase volume together as their customers grow.
The idea of proactive onboarding is fairly revolutionary. It's a `` why didn't anyone think of this before? '' type of an idea. Progressive profiling is already an emerging trend in onboarding, and Rownd takes this idea a step further.
If Rownd can gain the favor of developers — and more importantly — the users of their products, they can become a big company. Killing the login page is a lofty but worthy goal to tackle.
Sarus lets data scientists access work with sensitive data in a private way. The product proxies queries from users to dynamically ( and virtually) return private results ( or synthetic data samples of small datasets) without requiring the end user to see or access the private data.
If this description sounds a lot like JumpWire, you're right. Sarus and JumpWire are conceptually similar but serve different use cases. JumpWire encrypts sensitive data that's accessed by applications. Sarus keeps sensitive data private ( using a fancy technique called differential privacy) while still returning large, aggregated result sets for data scientists.
Functionally, the products are similar, but Sarus has a much more specific use case. I wouldn't even call them competitors.
Similar to JumpWire, I would broadly classify Sarus into Database Security. The product also maps to the Privacy By Design category, which includes data anonymization and developer-focused privacy tools.
Based on the discussion around their Hacker News launch, people definitely had questions, but the questions were mostly well-intentioned.
There was some feedback about clarifying how the product works, which isn't surprising. This is a different situation than Rownd — Sarus is solving an uncommon problem in a very different way. People seem interested in giving them the time to explain why and how.
The good and bad part about the users and problem Sarus is addressing is that it's specific ( or niche, perhaps). You could take that negatively and say it limits their growth potential. However, in the case of an early stage startup, I see it as a good thing. Sarus seems to know exactly what the product does and who it's for.
Data privacy for data scientists may seem like a relatively niche market, but it's not. Nearly every high growth startup, enterprise, academic institution, and government agency now stores and analyzes petabytes of sensitive data.
Allowing data scientists to do their work while simultaneously keeping data secure is actually an interesting predicament. The Sarus founders described it like this in their Hacker News launch:
It’ s a rightful objective to protect data but it should not have to hamstring all innovation. For most data science or analytics objectives, the analyst has no interest in the information of a given individual. They look for patterns that are valid across the dataset. Access to user-level information is just an unfortunate way to get there.
`` Access to user-level information is just an unfortunate way to get there '' is a great line. Prose aside, it's an insightful example of why Sarus can potentially be one of the first big engineering-focused privacy tools.
In adjacent use cases, engineers actually need to access the data but can't, so privacy is a pain. In the case of Sarus, data scientists don't even need or want to access the data — there just wasn't a way to let them do their work otherwise. Until now. That's why Sarus can be huge.
Strac detects and masks sensitive data exchanged by your company and third party services. In today's integration-first SaaS world, this type of data exchange actually happens a lot. Bad things happen when your sensitive data is all over the place — and especially in random third party services where you might not expect it to be.
A particularly acute example was the [ 24 ] 7.ai data breach that affected multiple Fortune 100 companies. [ 24 ] 7.ai is a customer support chat service that ended up collecting PII and credit card data from customers to resolve support issues. They got breached, and it created a super messy situation for their large customers.
The closest mapping in my existing cybersecurity ecosystem mapping is Data Loss/Leakage Prevention, but this feels inaccurate. Strac is like a secure file transfer system built for modern, API-based data exchanges instead of old-school file transfers.
Strac's near-term challenge seems to be product focus. This could just be my intuition, but it looks like the product is going in a few different directions.
The core set of features are around securely exchanging data with third party services. There is also a data redaction API — which is also helpful, but feels like an adjacent product.
This is the nature of startups. The product will get figured out when specific use cases clearly start gaining traction.
Longer term, the challenge is awareness. Companies integrate third party applications quickly and without consideration for security. An additional security layer like Strac increases friction in an otherwise simple integration process. The value of inserting Strac into the mix needs to be clear, especially for security engineering teams.
Protecting data exchanged with third party services is a huge win. It's not realistic to expect business teams to avoid third party integrations at all costs. The next best thing is to let them get the value they need without unnecessarily exchanging sensitive data.
Integrations with third party services are growing exponentially to the point of being a mega-trend. Companies like Zapier ( a YC company, incidentally) are entirely built around the idea of simplifying integrations between third party services. This trend is definitely not going away, so let's make it secure.
That's exactly where Strac comes in. If they can become the go-to solution for enabling secure integrations between services, they're going to be a big company.
Vista is a platform for centrally managing authorization for your applications. Instead of building custom authorization ( roles, permissions, etc.), just integrate Vista, and they 'll take care of it for you.
The core of the platform is an API. It also includes React components and other handy tools to make integration and implementation easier.
Vista fits into the Authorization category, although I didn't create a specific sub-category for external authorization platforms in the first version ecosystem mapping.
Like other developer-focused tools in this YC batch and beyond, the main driver of growth is gaining developer adoption. Vista is squarely in the mold of a developer-first, bottom-up adoption product. They have to win over developers to be successful.
From a developer's perspective, there are risks in partnering with a startup — and especially for something as core as authorization. If you 've built authorization in your app using any third party service and the company shuts down, you're in trouble.
External authorization carries a different level of risk than security products that aren't as deeply embedded into a product. The opposite is also a benefit for Vista, though: if customers choose to use Vista for authorization, stickiness and retention is high. Once Vista is integrated and working, there's no reason to switch.
The current wave of companies building external authorization products is also competitive. Sequoia-backed Oso is in this market, and Auth0 released a developer preview of their Fine Grained Authorization product in late 2021. No company has won the market yet, but the competition is heating up.
There have been many attempts at building an external authorization platform over the past decade, and no company has even come close to winning the market. You could interpret that as a vote against any company in the market; however, the reality is that someone is bound to win it…eventually.
Managing authorization has been a problem developers have faced for as long as applications have existed. Authorization is still a pain to build today. What does get built isn't always great, either — excessive permissions are one of the major contributing factors in data breaches.
A de facto standard for external authorization needs to happen, and now could be the time. Integrating with third party services for non-core product functionality is now widely accepted. Companies have also come to terms with externalizing authentication. Authorization is a much bigger level of commitment, but it's now in the realm of possibility. Whoever wins this market is going to be a big company — probably the next Auth0.
* * * This is a Security Bloggers Network syndicated blog from Strategy of Security authored by Cole Grolmus. Read the original post at: https: //strategyofsecurity.com/y-combinators-winter-2022-cybersecurity-privacy-and-trust-startups/ | general |
Cancer treatment and diagnosis backlogs during COVID-19 may affect cancer survival | Unlike the COVID-19 pandemic, the cancer pandemic has raged on for centuries, though it similarly afflicts people in all corners of the world. In 2020 alone, over 19 million people were diagnosed with cancer globally, and almost 10 million people die from cancer every year.
The COVID-19 pandemic has been devastating to those infected with the SARS-CoV-2 virus, with over 481 million confirmed cases and 6.1 million deaths.
The number of people who have fallen ill or died due to unintended consequences of pandemic control measures has yet to be determined, though these invisible costs of COVID-19 control measures are likely to be substantial.
I am a cancer doctor and health services researcher, and my team has found new evidence that will help count the invisible cost of the COVID-19 pandemic to the cancer pandemic.
For people with cancer, the direct consequences of the pandemic include a potentially greater risk of severe COVID-19 infection. The indirect consequences include delayed diagnosis of cancer, deferred tests and treatment delay. For example, we observed a seven-fold drop in biopsies required for skin cancer diagnosis in Ontario early in the pandemic, with a backlog of over 45,000 cases remaining six months later.
Large drops in cancer diagnoses and cancer surgeries have been observed across Canada and internationally. For example, in Ontario, we saw a 34 per cent drop in cancer diagnoses and a 60 per cent drop in cancer surgeries at the start of the pandemic in 2020. Most concerning is the slow recovery of cancer services following lockdown, leading to diagnostic and treatment delays for those with cancer.
These delays in diagnosis and treatment have many consequences. There are effects on quality of life and mental health while awaiting care. Waiting for cancer care can lead to worsening symptoms and progression to a more advanced stage in some cases. Treatments for more advanced cancer can have more side-effects and may not be as successful.
To provide evidence to guide the health system response to cancer delays in the midst of the pandemic, our unit performed a study of high-quality evidence on the impact of cancer treatment delays on survival.
We used information from over 1.2 million cancer patients from 34 high-quality studies on 17 conditions where surgery, radiation or systemic therapy are routinely used. We studied seven types of cancer — bladder, breast, cervix, colon, rectum, lung and head and neck — that together represent 44 per cent of all cancers diagnosed worldwide, every year. We measured the survival impact per four-week delay.
Our report published in BMJ found that across seven cancer types, a delay of even four weeks could be associated with reduced survival. For example, cancer surgeries for breast, colon, bladder and head and neck sites were associated with a mortality increase between six and eight per cent for each four-week delay. Sex, advanced age and socio-economic factors were often associated with disparities in waiting times. As the delay increased, the impact on survival became even greater.
What does this mean in practical terms? A team from McGill University and the Canadian Partnership Against Cancer ( CPAC) developed a model using information from our study on treatment delay and survival. They found that between 2020 and 2030, disruptions to cancer care during the COVID-19 pandemic could lead to about 20,000 additional deaths from cancer in Canada.
Given that the pandemic has affected global cancer care and that outside of Canada over 19 million people are diagnosed with cancer each year, the global additional deaths from cancer care delays could be substantial.
We now have standardized information covering seven cancers and all three major cancer treatment types demonstrating a link between waiting longer for cancer treatment and worse survival outcomes. If we had a new cancer drug that improved outcomes as much as timely treatment did in our study, societal precedent suggests we’ d pay in the five figures per patient for it.
So now what? More research needs to occur in this space. The impact of cancer care delay on more conditions needs to be studied and methods need to be standardized. However, there are important implications for care now.
Given the massive backlog in health services due to the pandemic, investment is needed and is happening at the federal level. This is welcome and important. For example, a 10 per cent increase in treatment capacity could reduce the predicted mortality impact of the pandemic delay in Canada from about 20,000 to 4,000.
As we face other health emergencies and possibly further waves of the COVID-19 pandemic, caution needs to be taken when extending cancer waiting times for reasons unrelated to a patient’ s health-care needs. The impact of these delays on cancer patients may take years to emerge, but they can be expected and must be factored into decisions on prioritizing and protecting limited health resources.
During the pandemic, keeping hospitals, clinics and staff safe from COVID-19 infection can ensure optimal resources for timely diagnosis and cancer care. Centralized waiting lists and team-based care for surgery and other services can ensure equitable waiting times for treatment.
Finally, innovation in how care is delivered ( for example, learning health systems) and in the care provided ( for example, treatments requiring fewer visits to hospital or less human resources) are very important.
It is crucial to treat the patients of the cancer pandemic on time, during the COVID-19 pandemic and beyond. | business |
China promotes traditional cures as Pfizer pill alternatives | As Hong Kong’ s outbreak became the deadliest in the world, among the aid Beijing sent to the financial hub were 1 million packets of honeysuckle, rhubarb root, sweet wormwood herb and other natural ingredients, all mixed according to principles of traditional Chinese medicine ( TCM).
Practitioners of the centuries-old medicinal system argue such herbal combinations can be just as effective as antiviral pills like Pfizer Inc.’ s Paxlovid.
“ Unlike Western medicine that targets the virus itself, the way TCM works against COVID is to first effect change in the environment of our human body, ” said Liu Qingquan, dean of Beijing Hospital of Traditional Chinese Medicine. “ Once the environment changes, the virus can no longer survive. ”
President Xi Jinping wants other countries to give China’ s herbal cures a chance. His government is promoting TCM to allies worldwide, sending traditional medicine specialists to Cambodia and supporting clinical trials in Pakistan, both countries that rely heavily on Chinese aid.
Russia in 2020 allowed pharmacies to sell Lianhua Qingwen, one of the most popular types of TCM used to treat COVID-19 patients, and the government of another authoritarian leader, Belarusian President Alexander Lukashenko, agreed last year to establish a center to produce TCM near Minsk.
Making TCM globally acceptable as a treatment option for COVID-19 is an important part of Xi’ s strategy to use the pandemic to elevate Chinese innovations and inventions. China has still not approved widely used vaccines from AstraZeneca PLC and Pfizer, instead developing its own vaccines and making them easily available worldwide.
To advance its soft-power goals, China needs locally developed vaccines and treatments, says Michael Shoebridge, director of defense, strategy and national security at the Australian Strategic Policy Institute, a think tank in Canberra. “ This is part of creating a Sino-centered world, ” he says. “ It’ s a door opener. ”
China is struggling to persuade skeptics to put aside doubts about medication that hasn’ t gone through the large, standardized clinical trials required by regulators with global credibility like the U.S. Food and Drug Administration or the European Medicines Agency.
Western medicine explicitly explains how the active ingredients of a drug are processed in the body, but TCM’ s proponents face challenges showing how the various components in a concoction work. While studies done in China claim TCM has benefits for COVID-19 patients, critics say there are problems in the way the trials are designed and executed, and these prevent researchers from reaching unbiased and convincing conclusions.
Customers stock up at a supermarket ahead of a phased lockdown in Shanghai on Thursday. China is struggling to persuade skeptics to put aside doubts about medication that hasn’ t gone through the large, standardized clinical trials required by regulators with global credibility like the U.S. Food and Drug Administration or the European Medicines Agency. | BLOOMBERG
Even Singapore, with a large ethnic-Chinese population accustomed to traditional medicines, has warned citizens not to take Lianhua Qingwen as a COVID-19 treatment. “ To date, there is no scientific evidence from randomized clinical trials to show that any herbal product, including Lianhua Qingwen products, can be used to prevent or treat COVID-19, ” Singapore’ s Health Sciences Authority said on Nov. 17. “ We strongly advise members of the public not to fall prey to unsubstantiated claims or spread unfounded rumors that herbal products can be used to prevent or treat COVID-19. ”
The U.S. FDA in 2020 sent at least six warning letters to companies selling Lianhua Qingwen and other TCM-based products purported to be COVID-19 cures, telling vendors that the products were unapproved and misbranded drugs.
Such warnings ignore the results of a clinical trial published in May 2020, according to Lianhua Qingwen’ s producer, Shijiazhuang Yiling Pharmaceutical Co.
“ It’ s found in the study in terms of clinical use that Lianhua Qingwen proved to be both safe and effective in treating COVID-19 in conjunction with conventional therapy as it could significantly relieve clinical symptoms of COVID-19 such as fever, debilitation, and cough, greatly improve pulmonary lesions, shorten the duration of symptoms, and increase the clinical recovery rate, ” the company said in a statement last June.
Lianhua Qingwen products generated revenue of about 4.3 billion yuan ( $ 676 million) in 2020, with year-on-year growth of 150%, according to Yiling’ s annual report from last April.
Yiling declined to comment on regulatory warnings against claims of TCM’ s efficacy against COVID-19 but said the company has never exported Lianhua Qingwen to countries where the drug has yet to get regulatory approval.
Meanwhile, researchers in China have published studies purporting to show the efficacy of herbal treatments and state media frequently quote Xi calling TCM “ a treasure of the Chinese nation. ” In May 2021, he said the COVID-19 outbreak had helped people gain a deeper understanding of TCM.
TCM promotion is about geopolitics, not science, according to Steve Tsang, director of the China Institute at SOAS University of London. “ If TCM is proved to be an effective cure, I am sure the whole world will rejoice, ” he said. “ The problem is that there is no solid evidence that it is. ”
As Hong Kong’ s outbreak became the deadliest in the world, among the aid Beijing sent to the financial hub were 1 million packets of honeysuckle, rhubarb root, sweet wormwood herb and other natural ingredients, all mixed according to principles of traditional Chinese medicine. | BLOOMBERG
A TCM component may not have any effect when used singularly but could work when combined with others, said Danny Wong, chairman of Hong Kong-based Medisun Holdings Ltd., one of the partners promoting the TCM therapy Jinhuaqinggan as a COVID-19 drug outside the mainland. The drug was approved in 2020 for treating Covid after domestic studies claimed it relieved symptoms such as fever, muscle pain and headaches.
“ The challenge to explain and unpack the working mechanism of TCM is like trying to figure out what exactly propels an automobile, ” said Wong. “ Is it the tires or the engine? They all contributed to moving the car forward. ”
Given such challenges in establishing TCM’ s efficacy, there are limits to what even friendly countries will do to help.
One of China’ s closest friends in Europe is Serbia, which in March 2021 reached a deal to manufacture state-owned Sinopharm’ s COVID-19 vaccines as well as TCM treatments and services. A year later, though, pharmacies in Belgrade have done little to boost sales of TCM cures and hospitals haven’ t added TCM to protocols for COVID-19 patients.
Even China isn’ t betting entirely on TCM, approving in February Paxlovid, the first foreign pharmaceutical product for COVID-19 to win acceptance from regulators.
With generic drugmakers worldwide now making inexpensive versions of Pfizer and Merck’ s antivirals, interest in China’ s herbal cures that pre-date Covid will likely fade, argues University of Liverpool professor of pharmacology and therapeutics Saye Khoo. Early in the pandemic, “ we went for the drugs we already had, and we didn’ t get a huge amount of antiviral benefit, ” he said. Now, “ we are not in that era. ”
Back in Hong Kong, officials are planning to send herbal remedies to every household. The city recently started receiving significant supplies of antivirals, creating a chance to compare them with TCM, said Dennis Lam, convener of the Hong Kong Alliance of Integrated Medicine Against Covid. “ This provides an opportunity for us to make a good randomized controlled trial, ” he said, “ so maybe we will be able to share more about how good they are. ” | tech |
Wol Kolade: “ Everyone is looking at Russia, Ukraine and the US: I am looking at China and Taiwan ” | Powering European private equity
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As the crisis in Ukraine deepens, Wol Kolade, the boss of mid-market PE firm Livingbridge, fears that the Russian invasion could embolden China to make a similar bid for Taiwan.
“ Everyone is looking at Russia, Ukraine and the US at the moment. I’ m looking at China and wondering what this means for them and Taiwan where most of our chips get made, ” he says.
“ That’ s sort of a longer-term play, but you wouldn’ t confidently say that because Ukraine’ s happened it’ s not going to happen in Taiwan. ”
As for the Ukraine crisis itself, Kolade is not optimistic of a solution any time soon. “ In a multi-polar world it is really quite scary because it’ s volatile and difficult to call how the different actors will behave. In a multi-polar world it is more likely that we will see these things pop up and that is quite frustrating. ”
So far, the Russian invasion of Ukraine has had a limited impact on Livingbridge and the firm has not put any deals on hold.
“ We have some IT support people we have had to move very quickly to support in Ukraine and surrounding countries: either moving them to a different part of the country or moving them from the country entirely, ” Kolade says.
As the son of a Nigerian diplomat, Kolade’ s childhood included a spell living in the region when his father was posted to communist-era Czechoslovakia.
As one of the most prominent business leaders of private equity in the UK, Kolade gives up days of his time each year to sit on the board of the National Health Service as well as other public bodies.
Asked why he volunteers his time for the unpaid work, the 55-year-old managing partner of Livingbridge answers simply that he wants to “ give something back ” to society, though he admits that the opportunity to learn about healthcare from the inside is not without commercial interest.
London-based Livingbridge mostly concentrates on investing in services ( consumer, healthcare, tech, IT and software) and does not invest in industrials or manufacturing.
“ We are focussed on thinking type businesses, ” is the way that Kolade describes the firm’ s £3.2bn portfolio, adding that he enjoys the process of identifying and backing entrepreneurs and the next big investment trends.
The firm is currently investing a £350m small-cap fund and its flagship £1.25bn mid-market seventh fund – its largest ever – which closed in May last year. “ Currently, we are still very much in deployment mode, ” he says.
Sweet spot The firm mostly invests in lower mid-market deals with enterprise values of £50m to £300m. “ We have a sweet spot of around £100m, which is the place we are trying to have most impact. Before each investment we ask ourselves ‘ what is the play here’ and ‘ how do we add value’? ”
Geographically, Livingbridge’ s investments are focussed around the UK, Australia and the US with only occasional forays into continental Europe.
His childhood dream was to become an astronaut, but decided to plump for a career in finance after first hearing about venture capital during an economics class at the age of 15.
“ I sort of thought, gosh, that sounds really interesting and it still stayed with me, ” he recalls. “ I kind of thought, you know what, that’ s what I want to do. And I studied engineering at university because there was no direct route into venture capital. ”
After attending King’ s College London and picking up an MBA at Exeter University, Kolade took up a place on Barclays Bank’ s prestigious fast-track graduate management entry scheme whose top alumni were, he recalls, given “ a free run of the whole bank ”.
After working in Barclays global risk department he then, at his own request, made the move into the bank’ s private equity operations. In 1993 he joined Livingbridge’ s predecessor Baronsmead on secondment from Barclays and never left.
The firm subsequently morphed into Isis Equity Partners, a name that was changed to Livingbridge in 2014 following the rise of the terrorist group Islamic State.
Kolade describes the highlight of his career so far as buying, along with a group of partners, the business that would become Livingbridge from the insurer Friends Provident in 2005.
Given the keys “ That was the moment where we went from being employees to being owners, where we took charge of our own destiny, ” he recalls. “ That was the moment where we were given the keys and could drive the car away. ”
His most challenging deal, he says, was navigating regulatory and jurisdictional problems in different European countries after buying Refresco, a Dutch manufacturer of fridges and soft drinks for branded beverage companies that was eventually sold onto 3i.
It was a commercially successful deal, with a return of 2.5 times initial investment and, as a result of an emphasis on internationalisation ( common to many of Livingbridge’ s investments), Refresco grew to become the largest such company in the world.
But navigating Refresco’ s expansion into other European countries was exceptionally challenging and influenced Livingbridge’ s decision to largely keep away from European investments in future. “ Afterwards we were like: yeah, we probably shouldn’ t do that again ”.
Asked about his most lucrative deals, Kolade cites investments into bike accessories company Wiggle and the casual clothing retailer Fatface, which both resulted in more than 10x returns on investment.
Sticks in the craw His least successful deal and “ one that still sticks in my craw ” was an investment into Gilbert Rugby Balls in the early noughties. “ We over-reached on that one, ” he says. “ It all relied on us being really, really good at distribution and it was terrible. We lost control and we lost a lot of money, which is kind of irritating. ”
“ You learn lessons from deals that go bad and our job is to take risk. If we’ re not taking risk, we’ re not doing our job properly. Having said that, you can reduce the risk profile and in that deal, we multiplied the risk profile. And so today what we constantly do is aim to reduce our risk profile. ”
“ We’ ve got a very good loss ratio of much less than 10% of the money we invest going bad, which is pretty good given we are in the risk game. ”
Recent deals include an investment in Venatus, a global advertising technology platform, and the acquisition of Everlight Radiology from Intermediate Capital Group.
On the subject of diversity and inclusion, public school-educated Kolade, one of the few Black business leaders in the City, says the private equity industry is improving slowly but more needs to be done.
“ There is improvement but we have got a way to go in terms of diversity, not just gender diversity, but also sexual orientation, age and ethnicity. So we shouldn’ t pat ourselves on the back that we’ re doing it. We should always make sure we can do better because we can.
“ Five years ago this was not even on the agenda, so there has been progress. Today people take it very seriously and investors take it very seriously so we also take it very seriously.
“ It’ s moved from being forced to do it to being people wanting to do it, which is a good outcome. ”
Kolade is on the advisory board of Level 20, a not-for-profit organisation that aims to improve gender diversity in the European private equity industry with the aim of ensuring that at least 20% of women in senior investment positions are women.
“ At Livingbridge we are fortunate to be already there which is helpful, ” he says.
Of the # 10,000blackinterns campaign to offer paid work experience to 10,000 Black graduate interns across British companies, Lagos-born Kolade says that the initiative – of which he is a co-founder and trustee – aims to be a practical response to a problem affecting companies the length and breadth of the country.
“ I don’ t like to be up there in the ether: I want to get stuff done and the 10,000 Black Intern thing is a concrete response to the problem, which is if we don’ t get the talent into the pipeline, we will have no talent. ”
Confidence to go higher “ We initially aimed for 100 internships and we delivered 500 and that gave us the confidence to go for the 10,000 number. This year there will be 2,500 internships across places which would never have seen a Black person. ”
While Kolade, who is a Conservative party donor, was well known as a critic of the Brexit referendum decision of 2016 he now says that Covid has superseded Brexit in terms of the impact on the UK economy.
“ We haven’ t seen fully what Covid means but the amount of money the country has had to borrow is enormous and will bring inflation: we have got many more problems than Brexit to worry about now to be honest, ” he says.
The pandemic has made Livingbridge keep portfolio companies for slightly longer than the three or four years that the firm usually holds a company for.
“ There was a period during the pandemic where you could literally sell nothing, ” he says.
Age: 55Lives: Haywards Heath, West Sussex.Family: Married with five children.
Education Lancing College, West Sussex 1988 BEng, Civil and Structural Engineering, King’ s College London 1990 MBA, Exeter University Business School
Career 1990-92: Fast-track management trainee, Barclays Bank 1993 – to date: Kolade became managing partner at Livingbridge in 1998 and is responsible for the strategic development of the firm. He led the buyout from former parent company Friends Provident in 2005 and since then, Livingbridge’ s AuM has grown from £300m to over £3bn.
Hobbies and Interests Kolade has particular interests in education and healthcare and over the years has undertaken chair, non-executive director and trustee roles at several not-for-profit and public service organisations including NHS England and Improvement; the Guy’ s and St Thomas’ Foundation; Somerset House, The London School of Economics and the British Private Equity and Venture Capital Association ( BVCA), which he chaired in 2007/8. In his spare time, he enjoys travelling and entertaining family and friends. He also enjoys skiing, tennis and going to the cinema and his favourite films are the Godfather I and II. He supports Liverpool Football Club.
Awards 2021: Received a CBE in the Queen’ s Birthday Honours for services to financial services. 2014: Kolade was named as one of the 100 Most Influential in Financial Services by PEN’ s sister title Financial News. He was also four times named as one of the 50 Most Influential in Private Equity in the years 2018-2021.
Founded: 1995AuM: £3.2bn as of December 2021Staff: 100 and growingBusinesses backed: 170+Typical investment: £10m - £150mOffices: headquarters in London with offices in Manchester, Birmingham, Boston and Melbourne.
2021 At a glance: Exits: 9Amount realised through exits: c £420mNew investments: 12
Source: Livingbridge
To contact the author of this story with feedback or news, email Mark Latham
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Should you get a second booster shot for COVID-19? | Live Science is supported by its audience. When you purchase through links on our site, we may earn an affiliate commission. Learn more
By Nicoletta Lanese published 4 April 22
Is a second booster recommended?
Last week, the U.S. Food and Drug Administration ( FDA) authorized ( opens in new tab) second booster doses of the COVID-19 vaccines made by Pfizer-BioNTech and Moderna. This authorization applies to individuals age 50 and older, as well as certain immunocompromised people ages 12 and older.
Dr. Rochelle P. Walensky, the director of the Centers for Disease Control and Prevention ( CDC), said that ( opens in new tab) second boosters are `` especially important for those 65 and older and those 50 and older with underlying medical conditions that increase their risk for severe disease from COVID-19. ''
So if you qualify for a second booster, is it worth seeking one out right away? And are there any potential downsides to getting the shot now?
Broadly speaking, there's a consensus that extra boosters are safe and that people aged 65 and older and immunocompromised people of all ages would benefit most from a second booster shot, John P. Moore, a professor of microbiology and immunology at Weill Cornell Medicine, told Live Science.
`` I think where there's differences of opinion is for healthy people in their 50s, '' Moore said.
Moore stressed that he is not a physician and therefore can't offer medical advice, but he's of the opinion that healthy individuals in their 50s can get the extra booster now if they want, but it's not necessarily a priority for them.
Related: Quick guide: Most widely used COVID-19 vaccines and how they work
Anyone age 50 and older can receive a second booster dose of either mRNA vaccine — Pfizer-BioNTech or Moderna — if it's been at least four months since their first booster dose of any authorized or approved COVID-19 vaccine, the FDA said.
Younger people ( those over age 12 for the Pfizer-BioNTech vaccine, or those over age 18 for the Moderna vaccine) can also get a second booster dose if they have conditions that impair their immune response.
`` These are people who have undergone solid organ transplantation, '' which involves being placed on immune-suppressing drugs, `` or who are living with conditions that are considered to have an equivalent level of immunocompromise, '' the FDA said.
The FDA justified its authorization of second booster shots based on several studies conducted in Israel.
One study, posted Feb. 1 to the preprint database medRxiv ( opens in new tab), included more than a million people age 60 or older who had either received one booster shot or two. The follow-up time was very short — only 12 days — but suggested that the rate of severe disease was about four-fold lower in the double-boosted group, Eric Topol, a professor of molecular medicine at Scripps Research in La Jolla, California, wrote in a blog post ( opens in new tab) last week.
Another study from Israel, posted on March 24 to Nature's preprint database ( opens in new tab), included more than 560,000 people ages 60 and older, and showed that those who received a second booster had a 78% lower death rate from COVID-19 compared with those who only received one booster.
Related: Coronavirus variants: Facts about omicron, delta and other COVID-19 mutants
But how long this boost in protection lasts is an open question.
`` The deficiency in our knowledge base is the lack of follow-up, maximal at only 40 days so far, for enhanced protection vs. severe illness, hospitalization and death, '' Topol noted in his blog.
As these people are followed over time, we should know how long the enhanced protection lasts — and there should also be more data on younger people available soon, he noted.
The available data suggest that second booster shots don't come with any notable safety concerns, according to the FDA.
The Ministry of Health of Israel sent the FDA a summary of safety surveillance data collected from about 700,000 people — mostly over age 60 — who received second booster doses of the Pfizer-BioNTech vaccine at least four months after their first booster doses. This analysis `` revealed no new safety concerns, '' the FDA noted.
The safety of the Moderna second booster was `` informed by experience with the Pfizer-BioNTech COVID-19 vaccine and safety information reported from an independently conducted study, '' the FDA said. This small study included 120 adult participants who received a first booster dose of Pfizer-BioNTech and then a second booster of Moderna. `` No new safety concerns were reported during up to three weeks of follow up after the second booster dose, '' the FDA said.
Regarding who should get the shot now, Topol wrote in his blog that he would recommend a second booster if it's been more than 4 to 6 months since your last booster dose and `` you are age 50+, you tolerated the previous shots well, and you are concerned about the BA.2 wave where you live, or that it's getting legs as you are trying to decide. Or if you are traveling or have plans that would put you at increased risk. '' ( BA.2 is an omicron subvariant that spreads more easily than the original omicron, known as BA.1.)
Related: 'Stealth ' omicron is in the US. Here's what we know about it.
But it's reasonable for some eligible individuals to put off getting a second booster, Topol wrote. For example, he said it's `` fine to wait if there's a low level of circulating virus where you live and work. '' You can check the case positivity rate in your county or state using the CDC's COVID Data Tracker ( opens in new tab); the tracker also shows the number of new COVID-19 cases, hospital admissions and deaths.
What about those who had an omicron breakthrough case? For those who 've had three doses of an mRNA vaccine and an omicron infection, there's little need for a second booster right now, Topol wrote.
So far, data suggests you shouldn't wait for an omicron-specific booster.
Scientists have been studying variant-specific boosters in mice and rhesus macaques, a type of monkey. Animals in these studies were exposed to the omicron variant after being boosted with either another dose of one of the original mRNA vaccines or the new, omicron-specific shot, Moore told Live Science. The omicron-specific boosters offered the same amount of protection as the original vaccine formulas.
`` The differences were subtle to unimportant, '' Moore told Live Science.
These studies were in animals though, so it remains to be seen whether an omicron-specific booster could offer people any added benefit over a normal booster, Topol wrote. Human trials ( opens in new tab) of such boosters are ongoing.
Even if omicron-specific boosters do wind up working better than those against the original strain, `` from my discussions with FDA, it is not likely the Omicron-specific vaccine will be available before late May or June, '' Topol wrote. `` So you can factor that uncertain added benefit and timeline into your decision '' to get a second booster sooner or later.
Some people may be concerned that getting a second booster against the original strain of SARS-CoV-2 could sabotage their immune system's attempts to ward off future coronavirus variants. So far, there's no evidence that receiving multiple booster doses against the same variant would have this undermining effect.
It is true that some experts have raised concerns about a phenomenon called `` original antigenic sin, '' in which the immune system's first exposure to a pathogen, whether through infection or vaccination, leaves a permanent `` imprint '' and shapes the immune response to similar germs in the future. For example, a first encounter with an influenza virus in childhood can affect how well the immune system responds to later flu infections or the yearly flu shot, Live Science previously reported.
Could original antigenic sin — also known as `` immune imprinting '' or `` antigen imprinting '' — influence how the immune system responds to future SARS-CoV-2 variants and variant-specific boosters? Studies ( opens in new tab) hint ( opens in new tab) that yes, a person's first COVID-19 infection or vaccination leaves some impression on the immune system, whether that hinders the immune response to new variants or boosters in the future is unclear.
`` I 've not been convinced that original antigenic sin is an issue here, '' Moore said.
Related: Omicron's not the last variant we 'll see. Will the next one be bad?
Thankfully, even though the current vaccines prime the immune system to react strongly tot the original SARS-CoV-2 variant, they still generate a range of antibodies that can latch onto multiple variants. By comparison, antibody responses to natural infection are much more narrow, a Jan. 24 study in the journal Cell found..
There is a chance that a new variant may crop up that effectively bypasses first generation vaccine-induced immunity. But in that case, antigen imprinting may be less of an issue.
`` My own take is that if a variant comes along that's horrific enough to show major immune evasion, that very property will make it something that a new vaccine booster is likely to be able to target usefully, '' drug discovery chemist Derek Lowe wrote in Science Magazine's In The Pipeline blog ( opens in new tab). In other words, a variant that looks drastically different from the original SARS-CoV-2 might be easier to take down with a new, specially designed booster.
`` Omicron isn't it, though, '' he wrote. `` It's different enough to be much faster-spreading, but it's similar enough for the current vaccines to still provide a huge amount of protection. ''
At this point, no one knows if or when the FDA might authorize an additional booster dose for those who have already received two.
Early trials of omicron-specific boosters are still underway, so it's not yet known whether those would offer an advantage over the first-generation boosters. While we await the results of those trials, more data should emerge about the benefits of the second booster doses in different populations.
Recent ( opens in new tab) studies ( opens in new tab) hint that, in general, the second booster dose may not offer as dramatic a bump in antibodies or as significant an increase in immune memory compared with the first booster dose. In general, this might hint that repeated booster doses may offer `` diminishing results, '' The New York Times reported ( opens in new tab).
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`` From what we know so far, the third dose is likely to be the most important, '' Moore said, referencing the first mRNA booster. This first booster follows a key period of time where the immune system consolidates its memory of the virus and establishes immune cell training camps known as `` germinal centers, '' according to Nature ( opens in new tab). The booster likely helps to cement this immunological memory while also broadening which features of the virus can be recognized by the immune system.
So will a third booster someday be necessary? For now, we don't know — and of course, the emergence of a new SARS-CoV-2 variant could complicate the question.
Originally published on Live Science. | general |
Hong Kong Leader Will Not Seek Second Term | After months of speculation, Hong Kong chief executive Carrie Lam announced at a daily press conference that she will not seek a second term, marking an end to her widely unpopular administration.
Hong Kong leader Carrie Lam unveiled at her daily Covid press conference today that she will not seek a second term while also thanking her team and family for their support.
« There’ s only one consideration and that is family. I have told everyone before that family is my first priority in terms of my consideration. They think it’ s time for me to go home, » Lam said.
According to a « Reuters » report citing unnamed sources, Lam had met with members of her cabinet this morning and also informed Beijing of her intentions prior to the public announcement.
Lam Administration
A lifelong civil servant, Lam took office in 2017 and oversaw one of the most tumultuous periods of Hong Kong’ s history.
Some of the key events that occurred under her administration’ s watch include the attempt to push an extradition bill that sparked pro-democracy protests, the enactment of the controversial national security law and the ongoing implementation of zero-Covid policies.
The Lam administration has become widely unpopular across Hong Kong society with approval ratings of just 26.6, according to a recent survey last month by The Hong Kong Public Opinion Research Institute.
John Lee
Also on the same day, chief secretary John Lee is reportedly stepping down to officially join the race to replace Lam as Hong Kong’ s new chief executive.
The 64-year old Lee was a security official during the 2019 pro-democracy protests and is widely seen as the front runner for the city’ s top state role. | general |
The price for Europe to wean off Russian gas keeps going up - News for the Energy Sector | Europe’ s ambitious timetable for building its way out of a dependence on Russian energy faces potential delays and billions of dollars in extra costs as the war in Ukraine makes steel, copper and aluminium scarce and more expensive.
A rush to replace Russian fossil fuels is prompting the continent to focus on shoring up flows of liquefied natural gas ( LNG) in the near term and increasing generation from renewable sources by 2030. Germany pledges to build two LNG terminals, France wants to resume talks with Spain about a connecting pipeline, and the UK seeks more homegrown wind, solar and nuclear power.
Yet prices for the necessary materials keep heading in one direction. Steel, copper and aluminium each touched records in the past 12 months, and the Bloomberg Commodity Spot Index jumped 46% during the same period. The spikes threaten to slow such undertakings as the European Union’ s blueprint to almost triple wind and solar capacity this decade — a colossal investment that could require about 52 million tons of steel alone.
“ This war has an impact, of course, on all those companies, including us, that are on the doorstep of making quite large-sized investments, ” said Fred van Beers, chief executive officer of SIF Holding NV, which makes steel platforms for wind turbines. “ It’ s putting our business case upside down. ”
Before the invasion, Russian gas was relatively cheap, easy to transport and in ample supply. Those factors, plus the anticipated opening of the Nord Stream 2 pipeline to Germany, helped persuade Europe to reduce its own production and start shuttering coal plants and nuclear reactors to focus on cleaner sources.
The EU imported about 155 billion cubic meters of gas from Russia last year, according to the International Energy Agency. In the aftermath of war, the bloc wants to cut dependency by two-thirds this year.
Higher Costs
About 30 billion cubic meters can be replaced by other suppliers, with the difference made up by renewables, nuclear and changes in consumption, the IEA said. For the EU, the sticker price for the infrastructure may be as much as 20% higher than before the war started, said Grant Sporre, an analyst at Bloomberg Intelligence.
“ The build-out is going to be more expensive than governments intended, ” Sporre said. “ We may see some projects being delayed as prices stay elevated. ”
The European Commission’ s transition plan involves installing 290 gigawatts of wind and 250 gigawatts of solar. The bill just for the steel amounts to 65 billion euros ( $ 72 billion) at current market prices.
Russia and Ukraine are among the biggest exporters of steel slabs used in building turbines and gas pipelines. While alternative sources are possible, costs for those are 50% higher than normal, according to Rysted Energy AS.
Compounding the problem is China’ s decision to lock down its steelmaking hub of Tangshan in an effort to control a Covid-19 outbreak.
“ There are surging costs in the supply chain for all steel products in Europe, ” said James Ley, senior vice president for Energy Metals at Rystad.
Copper is another vital ingredient, with high conductivity that’ s ideal for internal wiring and external cables. Europe requires about 7.7 million tons to meet its 2030 target, and this year’ s rally adds about $ 7.6 billion to the price tag, according to Bank of America Corp.
Then there’ s the aluminium needed for solar panels, turbines and the grids they connect with. Europe has a critical shortage because production dropped after soaring power costs reduced smelting profits.
Russia is the largest producer outside China, with its refined aluminium accounting for about 5% of global production. The market already was tight going into this year, according to BloombergNEF, and prices rocketed to a record in March. The risk that Russia’ s shipments could be throttled by potential sanctions helped fuel those increases.
“ The world might have to get by without Russian supplies, ” Andrew Forrest, chairman and founder of Fortescue Group Metals Ltd., said in an interview. “ It is certainly doable, but there’ ll be an adjustment period. ”
More grids will be needed to deliver huge amounts of renewable generation to where the electricity is needed. About $ 1.5 trillion in cumulative investment from 2020 to 2050 is needed to add new connections, according to BNEF. | general |
20 Minutes With: Contemporary Artist Dia Mehta Bhupal | Artist Dia Mehta Bhupal has always been drawn to the spaces around her.
“ From a young age, I have been inspired by architecture, not simply the environment we inhabit, but the spaces beyond, the environments both natural and man made that become a part of the daily landscape, ” Bhupal says.
This interest in the spaces we occupy and how they affect—and define—our day-to-day lives has been a driving fascination throughout her career.
Originally from Mumbai, India, Bhupal, 37, graduated in 2006 from The Parsons School of Design in New York with a degree in photography before embarking on a celebrated career that has seen her work exhibited in galleries and art fairs globally.
Recently, her focus has been on how art and the act of creative expression itself can offer a space for humanity to reckon with and heal from the traumas of global crises.
At the start of the Covid-19 pandemic, Bhupal and Neha Modi, co-founder of “ conscious clothing brand ” Pause, came up with “ The Corona Quilt Project, ” a community engagement initiative that called for everyday people across India to design their own quilted squares that were pieced together in public art collage installations.
The Corona Quilt Project is presented by New York-based creative consultancy The Art Lab Studio, which was founded by Jaipur and New York-based entrepreneur Sana Rezwan, in collaboration with Healing Arts India.
Right now, The Art Lab Studio is featuring the next iteration of Bhupal’ s quilting project in the form of a public textile art installation called “ Stories of Healing in Cloth, ” which is currently being shown at Nila House in Jaipur through June 30.
Bhupal says this project presents “ a unique textile art piece that embodies the spirit of healing through gestures of creative expression. ”
PENTA: You seem to be particularly fascinated by images of the mundane, of common objects, locations, features of daily life and presenting them in an unexpected, arresting way. What in particular draws you to that kind of subject?
Dia Mehta Bhupal: A waiting room, a supermarket, a public toilet, or a cinema theater—these are all landscapes to which we are accustomed, and their presentation is at once uncanny as it is insightful. As an artist I am interested in presenting to us what we already know to be real, albeit with a particular tension: spaces that we know to be brimming with bodies, here, are intentionally left entirely empty.
I often question what it means to be presented with a topography of absence.
The rapid consumption of images is something I respond to and also stay away from. There are a multitude of complexities between what we see and how we perceive what we see.
The Corona Quilt Project was founded during the initial weeks of the pandemic for individuals to take a pause and reflect on the current time; it was a way to connect people, discuss self expression and mental health, and bring communities together. The project draws inspiration from the AIDS Memorial Quilt quilt ( the national quilt project honoring those lost to the AIDS crisis in the United States, now located in San Francisco) and started with a simple conversation between two childhood friends, Neha Modi and myself.
The response has been overwhelmingly positive. We have received over 40,000 squares. The pandemic has been a period of difficulty, reflection, perseverance, and trauma. People appreciated that all they were being asked to do was just pause and reflect. The project grew organically because in India it's the first of its kind; a people’ s project, amplifying people’ s voices and community experiences, above all else.
The Corona Quilt Project presents a diversity of experiences, celebrating the strength and the resilience of people. The squares explore themes of home, safety, nature, the environments in which we exist, and the pandemic, each made through unique forms of mixed media and materials. The Project draws inspiration from the everyday and seeks to delight and inspire joy with those who experience it.
As a part of the growing, pan-India Corona Quilt Project, the installation will carry a multitude of 15-inch textile squares representing the range of textile craft traditions across Rajasthan. The artwork, made up of individual squares from artisans across India, also celebrates the vast and historically deep textile-based craft ecosystems that were made particularly vulnerable during the 2020 global pandemic, yet remained resilient and sustained through community-focused initiatives. The artwork developed through this project emphasizes the abundant capacity for community healing through creative expression and ancient knowledge systems that remain at the core of traditional crafts.
It has been a truly humbling experience to work with diverse submissions, ranging from children’ s drawings to first-hand representations from health workers and medical professionals that connect and collectively empower the community. As an artist, this project has been an extension of my larger practice starting with a small component to tell a much larger story. These expressions signify an intersection between past, present and future, between disciplines and between ideas.
Hope is re-imagination in probably the most difficult and challenging times we’ ve seen as a society. I believe as we use the expressive arts to think about hope we will discover perspective and healing. | business |
Packaged-Food Sales Are Still Strong as Dining Out Comes Back | High inflation and the likelihood that people will dine out more often as fears of Covid-19 fade are worries for packaged-food companies. Yet the latest data parsed by Piper Sandler show that retail sales are still strong for many brands, if down from their pandemic highs.
Analyst Michael Lavery took a look at U.S. retail-sales growth across the companies he follows, finding that it remained broadly positive in the four weeks ended March 20. Excluding newer entrants with very high growth, such as Oatly ( OTLY), Utz Brands ( UTZ), Sovos ( SOVO), and Vita Coco ( COCO), sales were up an average of 3.8% year over year, compared with 3.2% in the prior four-week period.
Among more mature companies, the biggest growers were Tyson Foods ( TSN) and Hain Celestial Group ( HAIN), up 14.5% and 12.5%, respectively. B & G Foods ( BGS) and Beyond Meat ( BYND) were the only decliners, falling 0.8% and 7.9%. It was the steepest decline for Beyond Meat since August 2021.
Looking at a two-year compound annual growth rate basis, retail sales at nearly all the companies were lower. That isn’ t a surprise, given that March 2020 marked the start of the stay-at-home orders that kicked of the frenzy of pandemic-era grocery shopping. Hershey ( HSY) was the only company that saw a two-year increase, of 1.4%.
Packaged-food companies have been raising prices nearly universally to pass on higher costs to consumers, which has investors watching sales carefully. The concern is that sticker shock at the grocery store, coupled with high inflation in energy and elsewhere, will cause shoppers to pull back. Yet brands have offered fairly upbeat outlooks: High savings rates and rising wages are two factors helping ease the pain of higher prices.
Barron’ s noted last spring that the pandemic boost wasn’ t likely to end as quickly as bears feared. | business |
Digital skills crucial for Africa’ s 15m new jobs target | With Africa’ s population expected to double and reach 2.5 billion people by 2050, the continent needs to create at least 15 million new jobs by 2025 to combat the unemployment crisis.
To obtain this target, governments will have to invest heavily in the tech and digital industries, and create green job opportunities, while modernising the agricultural sector to increase productivity.
This is according to the People’ s Charter on Jobs in Africa, a report created by the Jobs Now Africa Coalition as part of its new # JobsNowAfrica Campaign. The interactive platform is designed to outline the scale of Africa’ s unemployment crisis, where the public is encouraged to participate in a petition to urge governments and non-state partners to prioritise this pressing issue.
Following a six-month consultation process across seven African countries that account for a third of the jobs on the continent, including SA, the 40 organisations behind the coalition believe the continent is at the tipping point of what could be the economic breakthrough from the pandemic – but only if investments are made now to prioritise job creation and harness the potential of youth.
According to the report, Africa lost more than 20 million jobs at the peak of the pandemic. Without a commitment to invest in the digital economy, through developing new in-demand tech skills, the organisations behind the coalition warn the continent risks losing out on the next generation of leaders.
Figures from the African Development Bank Group show that while 10 million to 12 million African youth enter the workforce each year, only three million formal jobs are created, leaving more than half of the new entrants in the labour market unemployed.
The coalition stresses the importance of governments prioritising the creation of quality jobs more than any other issue, by channelling funds towards the tech and digital industries, while ensuring the successful implementation of the African Continental Free Trade Area.
Edwin Ikhuoria, executive director for Africa at coalition partner ONE Campaign, says: “ The African continent is facing an unprecedented unemployment crisis that has been exacerbated by the COVID-19 pandemic.
“ We can not afford to keep turning a blind eye to this pressing issue that has fuelled the rising instability and insecurity across the region.
“ Many of our youth are discouraged and slowly losing their spark and excitement for the future, and it’ s shameful that not more is done to support them.
“ Too much is at stake for us to continue with the current business-as-usual approach. Job creation must not be an afterthought but rather, tackled alongside other priorities such as pandemic recovery, healthcare and education. ”
The South African economy shed more than 270 000 jobs in the fourth quarter of 2021, with the country’ s unemployment rate climbing to 35.3% and 7.9 million unemployed people, according to Statistics South Africa.
As part of the solution to the unemployment crisis, analysts have been calling on South African organisations to tap into opportunities presented by the gig economy, as the sector helps develop new in-demand skills and create new employment avenues.
The Harambee Mapping of Digital and ICT Roles and Demand for South Africa Survey found that digital skills and services have the potential to pave the way for over 66 000 jobs in SA’ s ICT sector, two-thirds of which are entry-level roles.
Delivering his State of the Nation Address earlier this year, president Cyril Ramaphosa said SA is nurturing new growth and job creation opportunities, with a focus on emerging tech sectors, to help the millions of unemployed South Africans.
He said the present situation of deep poverty, unemployment and inequality in the country is “ unacceptable and unsustainable ”.
Pearl Thusi, South African actress and ambassador for the # JobsNowAfrica campaign, says: “ Africa has been a contradiction for far too long. A rich continent with poor people! Before COVID-19, we thought we had a major problem of joblessness, but when the pandemic hit, we saw an increasing crisis of job losses.
“ Africa lost more than 20 million jobs at the peak of the crisis. To the extent that people preferred to be infected than to be hungry because of job loss. Africa needs at least 15 million new decent jobs every year for its young people. Quality jobs more than any other issue should be the priority for governments. This is why the # JobsNowAfrica coalition is putting jobs back at the top of the agenda. ”
While inevitably the fourth industrial revolution is poised to contribute to both displacing and creating jobs, its long-term effect should be an increase in employment opportunities, notes the coalition.
“ The population of young people is growing faster than the ability of the continent to create job opportunities for them, and the gap is widening. That’ s why # JobsNowAfrica is the contemporary discussion to have, ” says Roy Telewa, CEO of Kenya’ s National Youth Council.
“ In Africa, unemployment and underemployment continue to be major obstacles to the full utilisation of human resources, despite relatively strong growth in the region over the last decade.
“ We need to ask ourselves: how do we harness the growing population of young people to bring about a demographic dividend, in order to bridge the gap between the rising population and the widening employment gap. ” | general |
Reflecting on the Great Resignation One Year Later | In early 2021, employment experts across the nation started to notice a troubling new trend: a growing number of workers were quitting their jobs en masse.
As the months went on, the phenomenon — fueled by the ongoing COVID-19 pandemic — continued, with more and more workers resigning from jobs they previously appeared to have been happy with. Known as the “ Big Quit, ” the “ Great Reshuffle ” or the “ Great Resignation, ” the trend eventually culminated with millions of workers quitting their jobs, month after month. In June 2021, an estimated 3.9 million people left their jobs, and there was a peak of nearly 5 million in November of 2021.
These job resignations occurred across the country but were especially focused in the South and the Midwest. Most people were leaving jobs within the food, service, and retail industries, usually as a result of wage stagnation, the rising cost of living, growing pandemic fears, and long-lasting job dissatisfaction. However, corporate leaders were not immune to the desire to seek something new either as more than 100 CEOs left their posts in the first half of 2021, a more than 100% increase from the same time in 2020.
Now, one year later, the impact of the “ Great Resignation ” on corporate America and the American workforce is clear. A pair of new studies have come out to help shine further light on exactly what helped to bring about the phenomenon and why it happened. It also offers a hint on what can be learned from one of the most turbulent employment eras in recent history.
A recent study from Pew Research Center shows that the majority of people who quit their current employment as part of the Great Resignation in 2021 did it as a result of low wages, little opportunity for advancement and feelings of disrespect in the workplace.
Pew’ s data comes from a February 2022 survey of 6,627 random, non-retired U.S. adults. That group included 965 men and women who said they left a job by choice last year.
The study also revealed differences in how race and ethnicity factored into the Great Resignation.
The study said non-white adults who quit their job in 2021 were more likely than white adults to cite a lack of flexibility, wanting to move to a different area, undesirable work hours or their employer requiring they get a COVID-19 shot as reasons for leaving.
Age also played a major role in who decided to quit their job and who didn’ t, with younger adults being significantly more likely to make that decision than older adults. People under 30 were 20% more likely to take part in the Great Resignation than those between the ages of 30 and 49. People over the age of 50 were the least likely to quit their jobs last year.
For many people who left their jobs in 2021, the answer to whether they should have quit their job appears to be “ no. ” In fact, some are now saying that the Great Resignation of 2021 has led to the “ Great Regret ” of 2022.
In a survey of more than 2,500 Gen Z and millennial workers by employment research site The Muse, researchers found that 72% of individuals who had quit their job in the last year regret the decision and now feel a sense of “ buyer’ s remorse. ” The survey found that many individuals felt their new place of employment didn’ t offer the same working environment they had been promised during the interview process, didn’ t provide the same benefits they had been expecting or was simply less fulfilling overall than their previous gig.
Kathryn Minshew, CEO of The Muse, has dubbed the feeling these individuals are experiencing as “ shift shock. ”
She said some people joined companies thinking they found their dream job, but there was a reality check for those people. Those looking for a job sometimes don’ t ask the right questions during the interview process and sometimes recruiters misrepresent the role, leading people to be disappointed in their new positions, she told The Outsider.
“ It’ s this really damaging phenomenon where people are brand new in a role, and they suddenly realize it’ s not at all as advertised, ” she added.
While a remarkable 80% of those surveyed reported that they feel that it’ s okay to leave a job after just a few months of employment, unhappiness with job changes because of The Great Resignation isn’ t just affecting young people.
In Pew’ s study of individuals who left their jobs in 2021, 22% of those surveyed from all age groups said that despite the country’ s more than 11 million current job openings, they had yet to successfully find new employment. In fact, one in five of those surveyed said that their job search had been “ very difficult. ”
Another 45% reported that they were either earning the same money as before or less, meaning their change in employment was not a profitable decision. And 46% said their opportunities for advancement had not increased while 47% reported that they are having the same challenges, or even greater difficulties, balancing work and family responsibilities.
In a recent survey from invoicing company Skynova, researchers reported that a large portion of the Great Resignation had also been fueled by what they called “ rage quitting, ” a phenomenon triggered by either work stresses, interpersonal conflicts or overall unhappiness with the workplace environment. Like the individuals polled by The Muse and Pew, these individuals who quit their job in 2021 were also plagued with guilt and remorse over their split-second decisions to leave a job.
In this case, 78% of individuals who left their job tried to get their job back after leaving. And while some individuals did report a decrease in stress and improved mental health following their decision, 40% said their stress levels increased following their resignation and 20% said they felt their mental health had worsened because of their choice.
Quitting a job you are unhappy with and finding a new job can be a good life choice, but research shows that’ s not been the universal experience for those who quit in 2021. One can end up in a new position they aren’ t happy with, working for employers they don’ t get along with, and they may be making less money with lower quality benefits, ultimately feeling even less satisfied by their work.
The takeaway? In a tight job market where it’ s more vital than ever to keep high-performing employees, the Great Resignation has yielded some important lessons for employers when it comes to hiring and recruitment. Those lessons include focusing on the human aspects of work, helping employees find purpose in their work and recognizing and responding to employee burnout. On top of this, employees want better pay, better perks and better benefits.
Subscribe to DiversityInc Best Practices for more on counteracting the Great Resignation and retaining a stable, happy and committed workforce.
Originally published at press.humana.com. Humana ranked No. 13 on The DiversityInc Top 50 Companies for Diversity list in 2021. The Humana Foundation, philanthropic arm of Humana Inc. for the past 40 years, continued its $ 5.5 million investment in six communities across the United States to improve greater health equity outcomes…
Originally published at newsroom.hilton.com. Hilton ranked No. 1 on The DiversityInc Top 50 Companies for Diversity list in 2021. Hilton, one of the world’ s leading hospitality companies, was today named the “ Best Workplace for Women in Greater China ” for the third consecutive year by Great Place To Work, the global…
Originally published at boeing.com. Boeing Company ranked No. 17 on The DiversityInc Top 50 Companies for Diversity list in 2021. When Connie So sees launch coverage of Boeing satellites, the CST-100 Starliner or even footage of the International Space Station, she knows her hands have played a vital and meticulous…
Originally published at basf.com. BASF ranked No. 12 on The DiversityInc Top 50 Companies for Diversity list in 2021. BASF Venture Capital GmbH ( BVC), the corporate venture company of BASF Group, announced today a strategic investment in Oceanworks, a sustainable plastic solutions provider that brings traceability and transparency through digitalization…
Originally published at about.att.com. Anne Chow is the CEO of AT & T Business. AT & T is a Hall of Fame company. Women’ s History Month is a time to reflect on women’ s accomplishments and the progress we’ ve made as a society. Over the past few weeks, I’ ve heard and read so many…
Originally published at sanofi.com. Sanofi U.S. ranked No. 27 on The DiversityInc Top 50 Companies for Diversity list in 2021. Sanofi launches its Diversity, Equity & Inclusion ( DE & I) Board, the first-of-its-kind in the pharmaceutical industry to feature outside advisors. Sanofi’ s DE & I Board will include three of the most influential voices in the DE & I…
Originally published at news.abbvie.com. Laura Schumacher is the Vice Chairman, External Affairs and Chief Legal Officer at AbbVie. AbbVie ranked No. 15 on The DiversityInc Top 50 Companies for Diversity list in 2021. AbbVie is honored to announce that Laura Schumacher, Vice Chairman, External Affairs and Chief Legal Officer at…
Originally published at pwc.com. PwC is a Hall of Fame company. Growth is the lifeblood of family business, essential to ensuring the business will continue to prosper for future generations. For the next generation of family business leaders, growth and sustainability go hand-in-hand. In new research from PwC, 65% …
Originally published at boeing.mediaroom.com. Boeing Company ranked No. 17 on The DiversityInc Top 50 Companies for Diversity list in 2021. The Invictus Games Foundation is pleased to welcome Boeing as Official Partner in a multi-year agreement supporting international wounded, injured and sick service personnel and veterans. Boeing is also announced…
A diverse and inclusive workforce extends beyond race and ethnicity to include cultural and religious practices. If offices in the U.S. continue to mark Christian holidays such as Christmas and Easter, it’ s important to also consider the position of those with non-Christian religious beliefs. This, of course, is a complex…
@ abbvie announces that Laura Schumacher, Vice Chairman, External Affairs, and Chief Legal Officer at AbbVie, has be… https: //t.co/NXtkzA4RSN March 30, 2022
In new research from @ PwC, 64% of next-generation ( NextGen) family-owned companies say their brand has the opport… https: //t.co/ZCyF3ty0ih March 30, 2022
Authenticity is encouraged in the # workplace given the benefits derived, including greater employee engagement and… https: //t.co/AzrhILUenA March 29, 2022
According to recent research by @ HarvardBiz, the difference in wages between # BIPOC workers and their counterparts… https: //t.co/tEkUpuwYoh March 27, 2022 | general |
Soon-to-rise digital hospital Weststate Private picks Rauland for nurse call system, bedside terminal | Health IT provider Rauland Australia has been chosen to deliver its nurse call system and patient engagement solutions to the soon-to-open Weststate Private Hospital in Queensland.
The A $ 60.5 million fully digitised hospital will be equipped with Rauland's Concentric Care platform comprising the Responder Nurse Call with associated clinical workflow, Concierge Patient Engagement, and Master Clock solutions.
The Responder nurse call system, according to Rauland, enhances communication flow to increase accuracy and reduce response time, errors, and wasted effort. It gathers data seamlessly for convenient decision making. It also features fall reduction management to improve patient safety.
The Concierge platform provides access to entertainment, phone and internet services via the bedside HiMed Cockpit. It also enables access to the patient's care plan, test results, and medical records.
Weststate Private aims to create a world-class healthcare service, focused on providing a `` hotel experience '' to patients, said CEO Neil Henderson in a media release. Set to open early next year, the surgeon-owned hospital will have 50 day and overnight beds, along with four theatres.
Adopting Rauland's acute care solutions, `` Weststate Private will be at the forefront of technological change in hospitals, '' claimed director and founder Kaushik Hazratwala.
He said they are taking a fully integrated systems approach that will enable unified data collection. The hospital will also measure key clinical performance indicators, as well as provide access to timely data to enhance staff and patient experience. It also emphasises accountability via data analysis for making informed care decisions.
With Rauland's Responder nurse call system, Weststate Private will be able to measure response times to ensure patients are receiving attention.
Hazratwala also sees that through its adoption of the Concierge patient engagement solutions, patient experience will `` greatly '' improve. `` Remote call accessibility via Concierge will also allow surgeons to speak directly to patients via the bedside terminals without the need to constantly be present in the hospital for face-to-face consultations, '' he added.
Last year, Rauland also secured contracts to install its nurse call system and patient engagement platform in other health providers in Queensland.
Aged care provider Apollo Care is adopting Rauland's Responder nurse call system at its three sites in Maryborough and Rockhampton.
Gold Coast Health has set up the Concierge bedside platform in the COVID-19 ward of Gold Coast University Hospital to reduce physical contact amid the rise of infections.
In February this year, Mercy Hospital, a tertiary surgical hospital in New Zealand, also deployed Rauland's bedside solution at its newly opened 22-bed Callaghan ward. | tech |
Why Cardi B Deleted Her Twitter After Skipping Grammys 2022 | We may earn commission from links on this page, but we only recommend products we love. Promise.
“ I can’ t I needs to protect myself. ”
Cardi B opted not to attend this evening’ s Grammy Awards in Las Vegas. Some fans gave her flak for her decision, given Cardi was nominated for Best Rap Performance for “ Up. ” ( She lost to Baby Keem and Kendrick Lamar for their song “ Family Ties. ”) The fan comments led Cardi to tweet a candid response about why she didn’ t attend the ceremony, then delete her Twitter entirely.
Before she deactivated her account, she wrote, “ I’ m deleting my twitter but On God I hate this fuckin dumbass fan base. You got the slow dumbasses dragging my kids all cause y’ all though I was going to the Grammys and I didn’ t the fuck? When the fuck I hinted I was going? just fuvkin stupid I can’ t I needs to protect myself. ”
Cardi is not the only nominee to skip tonight’ s ceremony by any means. Selena Gomez also skipped, and Taylor Swift and Kanye West, both Album of the Year nominees, have yet to be seen at the ceremony either.
Cardi spoke with Mariah Carey for Interview magazine last February about what an average day has been like for her amid the coronavirus pandemic. She mentioned the role of Twitter in her life at the time. “ During the pandemic, the average day is me waking up with a lot of ideas in my head, so I’ m always calling my team, trying to make whatever I have in my head happen, or I’ m wondering about a business venture so I call my lawyer, ” she said. “ And sometimes I go on Twitter, I go to blogs, I see what’ s going on in the world. I try to stay off it most of the time, because sometimes it’ s such a bad vibe. I usually wake up around noon and my daughter wakes up at 3:00 p.m., so I really have no time to just work, work, work, work. ”
At the moment, it’ s unclear whether Cardi’ s quitting the platform is temporary or permanent. | general |
The Infrastructure of Recovery by Riccardo Puliti | Even before the pandemic, overall investment in physical infrastructure such as highways, power lines, and internet cables lagged behind what was needed to meet development goals. To maximize infrastructure’ s contribution to the global economic recovery and support green and inclusive growth, four imperatives stand out.
WASHINGTON, DC – Physical infrastructure has a critical role to play in supporting the post-pandemic recovery and in laying the longer-term foundations for green, resilient, and inclusive development. A growing body of evidence highlights its contribution to a wide range of development indicators, including employment, productivity, income, inequality, trade, and human-capital formation.
Yet, across much of the developing world, infrastructure remains woefully inadequate. Some one billion people live more than a mile from an all-season road, 760 million lack access to electricity at home, and 450 million live beyond range of a broadband signal. Even where these services are available, they are frequently erratic and unaffordable. The disruptions caused by unreliable infrastructure cost individuals and businesses hundreds of billions of dollars annually, and the world’ s poorest and most fragile countries have the most expensive broadband, electricity, and transportation services.
Even before the COVID-19 pandemic, investment in infrastructure was well below the levels needed to achieve global development goals. And since the pandemic, spending has been squeezed further. While many developed economies have implemented stimulus packages to support economic recovery – often with infrastructure components – the world’ s poorest states lack the fiscal space for such measures. The last G7 summit highlighted this issue, as leaders called for enhanced efforts to fund infrastructure development in low- and middle-income countries ( LMICs).
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Writing for PS since 2022 1 Commentary
Riccardo Puliti is Vice President for Infrastructure at the World Bank.
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Like previous disruptions to the global economy, Russia’ s war in Ukraine has highlighted the fallacy of relying on markets alone to mitigate risks and strengthen countries’ resilience. Neoliberalism has failed yet another test and must finally be replaced by a new economic vision based on new values.
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| general |
Daily Update: April 4, 2022 | On February 28, 2022, S & P Global completed its merger with IHS Markit, the next step in delivering data, technology and expertise that accelerates progress.
As great as last year was for our company, in many ways 2022 is shaping up to be even better. In February, we closed a transformative merger with IHS Markit. We believe combining our two companies will create substantial long-term value for all our stakeholders.
The S & P Global Foundation is about much more than philanthropy—we are about making a difference by finding and developing essential connections between the knowledge- and skill-driven work of S & P Global and the needs of society.
As the Russia-Ukraine conflict continues, the metals industry is feeling the effects. Prices for metals have risen sharply amid high demand and supply chain issues, along with imposed sanctions against Russia.
With a full scale invasion of Ukraine now under way, stock markets, global trade, energy markets, and commodities markets are all registering the impact of a new geo-political reality.
In Europe, market constraints, extreme weather events, and geopolitical tensions have caused gas and power prices to skyrocket, creating an energy crisis that has left the region’ s energy and industrial industries concerned.
Start every business day with our analyses of the most pressing developments affecting markets today, alongside a curated selection of our latest and most important insights on the global economy.
After starting the year strong, the global economy and credit markets are now confronting downside risks stemming from the Russia-Ukraine conflict, persistent inflationary pressures, forthcoming higher interest rates, and the lingering pandemic.
Global macroeconomic and credit conditions are set to experience notable upheaval from geopolitical, confidence, and market shocks, according to S & P Global Ratings’ latest economic and credit outlooks.
The Russia-Ukraine conflict’ s direct disruptions to energy, agriculture, and other trade and capital flows have sent energy and food prices soaring—further complicating supply chains and increasing inflationary pressures, and creating new challenges for central banks as they approach aggressive monetary policy tightening. These factors are playing out as the pandemic plows on, with many economies managing to live with the virus while others continue to implement low-tolerance containment practices.
S & P Global Economics now expects global GDP growth of 3.6% this year after lowering its forecast due to these converging risks by 0.6 percentage point from its previous forecast..
“ While the global economic impact of Russia's invasion of Ukraine has been modest so far, there is no cause for complacency. The longer the conflict drags on, the higher the risks. Buffers built up by households during the worst of the pandemic are sizable, but they will not last forever, ” S & P Global Ratings Chief Global Economist Paul Gruenwald said in the second-quarter global economic outlook. “ The fall in confidence could pick up speed if the conflict and associated economic pain on all sides drag on. The worst of the economic impact from the conflict is therefore likely still to come. ”
As the beginning of 2022 has marked a turn in the positive credit momentum seen since last year, global credit conditions face prominent risks from the potential escalation of the Russia-Ukraine conflict or any expansion of sanctions onto gas and oil exports to Europe; central banks’ struggle to control inflation without choking economic growth, leading to higher borrowing costs especially for lower-rated credits; persistent supply disruptions and high commodities prices squeezing profit margins; and new COVID variants, according to S & P Global Ratings.
“ While pale in comparison to the tragic human costs, the detrimental effects of the Russia-Ukraine conflict on global economic and credit conditions are becoming more pronounced, with measurable implications for our macro forecasts and credit ratings, ” S & P Global Ratings Global Head of Analytical Research and Development Alexandra Dimitrijevic said in the second-quarter global credit conditions outlook. “ Widening credit spreads in major markets suggest investors are becoming somewhat more risk-averse. Moreover, the uncertainty around the crisis and its ramifications, as well as the acceleration of monetary-policy tightening, have led to a pause in debt issuance at the lower end of the credit spectrum. Mounting challenges will likely weigh on the credit outlook for the rest of the year, depending, in large part, on the evolution of the conflict. ”
Today is Monday, April 4, 2022, and here is today’ s essential intelligence.
U.S. nonfarm payrolls increased by 431,000, with a net 95,000 job gains the prior two months, according to the Bureau of Labor Statistics ' ( BLS) March jobs report. This underscores a strong economy. The report also puts the Fed on solid ground to act, confident that the U.S. economy can absorb tighter Fed policy and still grow.
The S & P GSCI posted its best quarterly return in decades, as inflation continued to post the highest readings in decades. Commodities rose another 9.63% in March after an 8.8% rise in February. Geopolitical conflict and inflation were the two main reasons for the broad-based uptick in commodities prices. The S & P GSCI Energy continued to lead the way last month, up 12.47% in March. The uncertain supply situation from Russia, the world’ s largest natural gas exporter and third largest oil exporter, led the U.S. to release a record amount of emergency oil from the Strategic Petroleum Reserve. Germany, highly dependent on Russian energy, initiated an emergency plan that could lead to energy rationing.
Asia's sustained oil demand revival over the last few months may face a fresh setback following COVID-19 outbreaks in China and other countries in the region. While sharp pull back in consumption appears remote at this stage, markets are keenly watching if Asia's top oil consuming nations resort to more lockdowns to stem the spread of the pandemic. In the latest episode of Oil Markets, Sambit Mohanty, Asia Energy Editor at S & P Global Commodity Insights; Jonathan Nonis, Associate Editorial Director for Asian oil products; and J.Y. Lim, Advisor for Asia-Pacific oil markets, discuss the possibility of another round of oil products demand destruction, Asia's crude buying strategy amid fears of a demand slowdown, and the impact on trade flows.
In the latest episode of ESG Insider, hosts Lindsey Hall and Esther Whieldon explore the potentially wide-reaching implications for investors, companies, and climate disclosure globally. To help understand the SEC's proposal as it relates to audit and attestation requirements, they talk with Maura Hodge, IMPACT and ESG Audit Leader at professional services firm KPMG. They also discuss the challenges of measuring Scope 3 indirect emissions with their colleague Dr. James Salo, who heads environmental research & ESG modeling at S & P Global Sustainable1. And to explore legal implications surrounding the proposal, they talk with Mellissa Duru, special counsel at law firm Covington & Burling and co-vice chair of the firm's ESG practice. Mellissa previously worked at the SEC in its Corporate Finance Division and as a lead adviser to former Commissioner Kara Stein on the SEC's ESG-related regulatory policy.
Feature: U.S. Airlines Cast A Wider Net In Search For Sustainable Aviation Fuel Supply
As U.S. airlines seek to lock in sustainable aviation fuel supply to reach their 2030 greenhouse gas emissions reduction goals, many are looking beyond suppliers who produce SAF using traditional feedstocks like hydrogenated vegetable oils and tallow. With more renewable diesel and SAF projects starting up, renewable feedstock supplies are tightening, increasing costs. The price of key soybean oil feedstock averaged 75.86 cents/lb in March, compared with the year-to-date average of 68.22 cents/lb, according to Platts assessments from S & P Global Commodity Insights.
Experts believe that while new EU regulations associated with the Digital Markets Act could have a significant impact on affected companies, enforcement will be the main determinant in ensuring the laws are effective. The European Council and European Parliament on March 24 approved the Digital Markets Act, or DMA, a framework of new initiatives intended to curb the dominance of Big Tech companies and related entities in Europe's digital landscape. The DMA's measures are designed to reduce the power of digital `` gatekeepers, '' which are companies considered to hold too much market concentration, thereby preventing competitors from entering a market. The DMA does so by determining which businesses can interact on or alongside their platforms and the way they can operate. | business |
Asia crude oil: Key market indicators for April 4-8 | In this episode of the Oil Markets Podcast, S & P Global Commodity Insights editors Paul Hickin, Emma...
Weather delays at major East Coast Mexico products ports and a challenging gasoline arbitrage on the...
After settling at its highest price in over a decade on April 7, the NYMEX Henry Hub prompt-month...
Crude oil prices are expected to be rangebound in the April 4-8 trading week as ongoing supply concerns arising from Russia's invasion of Ukraine are countered by concerns over the impact on demand of the COVID-19 resurgence in China.
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Front-month June ICE Brent crude futures stood at $ 103.66/b at 0200 GMT April 4, up 2 cents/b from the 0830 GMT Asia close April 1.
* * Market participants are awaiting the release of official selling prices for May loading crude cargoes by Middle Eastern producers in the week before spot trade for the month kicks off.
* * Saudi Aramco is expected to hike OSPs by around $ 4- $ 5/b for all its grades bound for Asia, with other producers expected to announce similar rises.
* * Demand cues for the week are mixed, especially from China and Japan. While China battles a new COVID-19 surge, Japanese refineries are entering turnaround season.
* * India remains a key Asian buyer in APril, with the country's demand for oil and products expected to grow in the weeks ahead.
* * The Dubai cash/futures ( M1/M3) spread averaged $ 6.70/b in the week to April 1, narrowing from $ 7.43/b the week before.
* * Intermonth spreads were wider during mid-morning trade in Asia April 4, with June-July pegged at 95 cents/b, down 21 cents/b at the Asia close April 1.
* * The June Brent/Dubai Exchange of Futures for Swaps was pegged at $ 7.05/b mid-morning April 4, down from $ 8.07/b at the Asia close April 1.
* * Trading activity in the Asia-Pacific sweet crude market was expected to remain thin into the last week of the May loading cycle, with most end-users having already covered their requirements.
* * For regional crudes, market participants will look out for spot deals on Malaysia's Miri and Kimanis grades, with overhang barrels heard in the market.
* * For heavy sweet crudes, trading activity for Australia's Van Gogh is expected to emerge this week, while clarity on trade details for May-loading Pyrenees are awaited.
* * Traders are also awaiting the release of Indonesia's March ICP and Brunei's February OSP this week.
* * The arbitrage flow of US ' WTI Midland crude into Asia remains sparse following CPC Taiwan's buy tender for June delivery barrels amid a narrowing WTI/Brent spread.
* * Trading activity for June delivery cargoes of Brazil's Tupi crude is expected to remain muted after earlier deals, and as China's COVID-19 concerns weigh on demand.
* * Crude oil futures are expected to be rangebound this week as the market monitors a two-month truce in Yemen between Houthi rebels and a Saudi-led coalition that started April 2, ongoing concerns over the war in Ukraine, and surging COVID-19 cases in China.
* * The EU on April 3 called for more sanctions against Russia, with EU ministers discussing ending Russian energy imports, after Ukraine accused Russian forces of war crimes near Kyiv. Any ban on Russian energy imports by Europe will likely throw oil markets into disarray.
* * The June contract for ICE Brent futures fell 11.1% on the week to settle at $ 104.39/b April 1, while the May contract for NYMEX light sweet crude fell 12.8% over the same period to $ 99.27/b.
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Viktor Orbán: Hungary's controversial authoritarian prime minister secures yet another term in national election | Having held power continuously since 2010, Hungary’ s Viktor Orbán is the longest serving prime minister in Europe. Now, as the dust settles on the latest election, he is beginning yet another four-year term.
Orbán faced down a challenge from a six party-strong opposition during the election campaign to hold on to his two-thirds super majority in parliament. His efforts to shore up power in recent years have once again delivered the vast majority of parliamentary seats to his Fidesz party.
Orbán is still the most successful politician in Hungary even if he owes that success to questionable tactics. A report from the Central European University’ s Democracy Institute accuses Fidesz of sabotaging the vote by rewriting electoral rules to suit its own needs and deploying state power to control the media and public institutions as part of a “ systematic effort to rig the elections ”.
Nevertheless, such manipulation can not account for the opposition’ s failure to make itself more relevant to the Hungarian electorate. The aim had been to bring six parties together to propose an alternative coalition for government with Péter Márki-Zay, the non-party-affiliated mayor of the Hungarian county town of Hódmezővásárhely, at the helm. But as the Hungarian political opinion survey guru Gábor Tóka warned, the opposition was unable to become “ one giant ”, instead remaining “ six small people ”.
The opposition ran a campaign that targeted Orbán personally over issues such as the war in Ukraine, inflation and the decision to shun Pfizer vaccines in favour of Russia’ s COVID vaccine Sputnik V. But convincing voters that a sprawling multi-party composition would be a viable alternative that could solve these problems was not ultimately possible.
Although the coalition held together throughout the campaign, there remained a very real prospect of it collapsing almost immediately under the strain of government were it to have won. A strong sign of this was the sheer volume of right-wing votes that ended up going to extremist party Mi Hazánk – proof that these voters were not happy to see their regular party Jobbik joining the opposition coalition. As a result, Mi Hazánk has secured enough votes to enter parliament for the first time.
All this was enough to discourage voters from straying away from the extreme continuity of a government that has been in place for over a decade. Clearly sensing a vulnerability in the diverse electoral goals of the opposition, Orbán focused his campaign on promising stability and protecting the nation in a time of uncertainty.
The war in Ukraine has certainly put Orbán in an uncomfortable position. Hungary is heavily dependent on Russia for energy and commerce and Orbán has not condemned Russian president Vladimir Putin to nearly the same extent as most European leaders.
Orbán’ s response to criticism on this point was to warn that the opposition parties would cut off Russian gas if elected to government, resulting in the collapse of the Hungarian economy. In his victory speech, Orbán referred to Brussels bureaucrats, the international media and even Ukrainian president Volodymyr Zelenskyy as his “ opponents ” in this election.
However, it seems unlikely that voters would support Orbán for this rhetoric as opposed to supporting him in spite of it. The question therefore becomes why they continue to back him. Certainly media freedom is highly compromised in Hungary and the public media has served as a mouthpiece for the government all throughout the campaign period.
It does however appear that rather than reacting against rises in inflation, energy prices and the general cost of living, voters endorsed a leader they know rather than trying someone new. Both the poorest areas in the north east and the richest regions of western Hungary gave Orbán significant support. The opposition, as before, remains limited to Budapest despite some increases in Fidesz support there as well. The western-oriented, liberal and Europe-focused narrative did not appeal to the electorate.
The electorate has given Orbán a pass on his position regarding Russia, but this will be a defining issue in the opening months of his new term – at least internationally. When it comes to Putin, Orbán is radically out of step with his European counterparts.
Hungary has operated as part of an informal alliance with Poland in recent years, challenging Brussels over the EU’ s approach to democratic principles. But this partnership has been weakened by differing views on Ukraine. Other countries in the region that have traditionally supported Orbán’ s anti-immigration politics now find themselves drawn closer into the European fold, offering support to Ukrainian refugees alongside everyone else.
The Hungarian election results show that “ illiberal democracy ” can exist in Europe, even as it faces a threat from Russia. Indeed, another authoritarian leader with close links to Russia is projected to win an impending election in Serbia, too.
It is still possible that Hungary might act with the European camp in opposition to the war in Ukraine. But such an alliance may be driven more by economic priorities than by a desire to defend liberal and democratic values. | business |
Market Movers Asia, April 4-8: Asian crude buyers eye US SPR release; COVID-19 disruptions hit China’ s metal industry | In this episode of the Oil Markets Podcast, S & P Global Commodity Insights editors Paul Hickin, Emma...
Weather delays at major East Coast Mexico products ports and a challenging gasoline arbitrage on the...
After settling at its highest price in over a decade on April 7, the NYMEX Henry Hub prompt-month...
On this week's S & P Global Commodity Insights ' Market Movers Asia with Rituparna Nath: Crude buyers in South Korea and India are eyeing surplus barrels after the US announced last week it will release 1 million barrels per day from its strategic reserves. ( 00:14)
This week, the metal industry is facing disruptions due to fresh COVID-19 outbreaks in China, container freight rates are set to rise this month, and spotlight is on the World Agricultural Supply and Demand Estimates report.
But first, Asian crude buyers will watch out for additional supplies after the US announced last week it will release 1 million barrels per day from its strategic reserves. The US is expected to release 180 million barrels from its reserves as it looks to rein in rising gasoline prices.
The SPR release has raised hopes among US crude customers like South Korea, India, Taiwan and Thailand of surplus barrels coming to Asia. For instance, South Korea, one of the biggest customers of US crude in Asia, is keen to take as many cargoes from the US as possible as it continues to favor competitive US barrels.
According to Korea National Oil Corp. data, South Korea paid an average of 90 dollars a barrel for US crude shipments in February, lower than the price for shipments from Saudi Arabia and Kuwait.
That brings us to our social media question for the week: Will the release of strategic oil reserves by the US rein in sky-high gasoline prices? Share your thoughts on Twitter and LinkedIn.
In metals, fresh COVID-19 outbreaks in China have disrupted operations in the steel, aluminum and copper industries.
In steel, the recent lockdown in Shanghai is expected to weigh on manufacturing activity this month, adding further pressure on domestic steel demand. Aluminum prices are also expected to remain under pressure, as destocking has been disrupted. In copper, inter-provincial transport of raw materials has been disrupted, which may impact operations of some smelters in north China.
The container market is also facing disruptions due to COVID-19. Freight rates are expected to rise in April and May after several carriers announced price hikes, after disruptions in ocean trade due to the virus outbreak. While the trade volumes from China are currently low due to curtailed manufacturing operations, market participants have expressed concerns about long vessel queues and cargo backlogs.
On March 30, the Platts Container Index was nearly 41% higher from a year ago.
Do check out the recently launched Platts Container Rate and Platts Bunker Charge Assessments for the Indian Subcontinent to East Coast North America route. These assessments by S & P Global Commodity Insights aim to give our subscribers a deeper insight into Asian trade.
And finally, in agriculture, the World Agricultural Supply and Demand Estimates report will be released this week. The report, released by the US Department of Agriculture, will provide future trade cues amid tight wheat supplies as the war in Ukraine rages on. Wheat exports from India and Australia are expected to increase in the next few weeks, which may compensate for the current supply shortfall.
Faced with surging grain procurement costs, Asian corn buyers will look for cues on US stocks.
In palm oil, markets may remain under pressure this week as top vegetable oil buyer India extended its stocking limits on edible oils and oilseeds by six months. Meanwhile, demand for cooking oil from China is expected to remain bearish amid the virus outbreak.
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'Kafkaesque ' true stories of ordinary people: inside the first days of COVID-19 in Wuhan, China | We have lived through two tumultuous years as the COVID-19 pandemic has swept through Australia. Our Prime Minister Scott Morrison took the lead, for domestic political purposes, in calling for an investigation into the origins of the virus in the Chinese city of Wuhan.
In January 2021, China finally agreed to let an international team of experts led by the World Health Organization into Wuhan to investigate. The findings of the team were inconclusive, because the Chinese authorities were not very cooperative and refused to approve a follow-up investigation.
People who are curious to know why China is so resistant to outside investigation should read this book.
Its author, Murong Xuecun, is a popular Chinese novelist known for his critical stance toward the Chinese government. The book collects the true stories of eight people in Wuhan who endured the early months of the pandemic, from November 2019 to April 2020: from when the first signs of the virus were detected, to when China declared the Party’ s victorious conquest of COVID in Wuhan.
Murong himself was not in Wuhan for most of that period. Risking his own safety, he sneaked into the city in April, interviewed eight people about their experiences, and then fled to another province, where he booked into a hotel and wrote up his interviews. He then departed China and is currently staying in London. He has escaped the fate of being denounced, silenced or even imprisoned, as has happened to several other “ citizen journalists ” who had gone to Wuhan and reported on social media about what had transpired.
Murong’ s revelations are different from the other writers’ postings. The eight true narratives in Deadly Quiet City are told in the first person by Murong, who skilfully captures their thoughts and feelings – their fears, their encounters with death, their anger, their losses. Each story provides background information, placing the featured individuals in context, then follows their reaction to the catastrophe of those few months from November to April.
Read more: I was the Australian doctor on the WHO's COVID-19 mission to China. Here's what we found about the origins of the coronavirus
Murong meticulously marked the dates and even times of critical moments: when doctors and scientists first noticed the virus; the date when Li Wenliang first alerted his circle of colleagues that a deadly new disease had stricken his hospital patients, only to be warned by local officials to stay silent; the day he died from the virus; the dates of important official announcements; the day that WHO confirmed the virus was a human-to-human transmittable variant; the date Wuhan was locked down; and the date the lockdown was lifted.
We learn what each of the eight individuals was doing during these periods. An old illegal motorcyclist taxi driver, at the bottom of the economic and social ladder, was grateful that the pandemic had helped him make a bit more money, because there was no other means of public transport. He ferried infected people back and forth between homes and hospitals and waited in queues as his clients desperately tried to get admitted.
Another of the eight, a writer and member of the middle class, whose online essays tended to be critical of the government, managed to fly out of Wuhan to Guangzhou at four in the morning on the night the lockdown was announced. On hearing of Li’ s death, he immediately started an online campaign, “ Never Forget Li Wenliang ”, to crowdfund a statue of the doctor. Within a couple of days, the state security bureau put him under house arrest.
Some of the eight or their relatives contracted COVID. They recounted their encounters with heartless bureaucrats in graphic detail. Some of them had lined up for hours trying to see a doctor, or desperately made dozens of phone calls to friends and relatives who might have contacts with powers that be, to be able to find a hospital bed. Most had seen the chaos in hospitals: crying, begging, patients collapsing or dying while waiting.
A hospital cleaner had propped up her sick husband on a bicycle to search for a hospital that would take him. Those who successfully got into hospital were slapped with medical bills totalling a year or two of their annual wage. They all confronted dismissive, callous bureaucrats trying hard to shift responsibility. If they dared to complain on social media – describing their sorry state, begging for help, and trying to raise money – they invited the presence of the police.
The stories also record humanitarian responses. The motorcyclist taxi driver had waived charges for sick people poorer than him. Pleas on social media for help to pay medical bills brought in needed money.
Another of the eight, Zhang Zhan, a citizen journalist who travelled to Wuhan when she heard news of the pandemic, was able to raise enough money to allow her to stay in Wuhan to post her daily reports on social media. In May she went missing. It was later revealed that she is in jail, sentenced to four years. She has been adopted by Amnesty International as a prisoner of conscience, and the latest news is that she is on a hunger strike.
There are many things we can learn about China from these eight stories. COVID has amplified the problems of an authoritarian system: endemic bureaucratic inefficiency, contemptuous treatment of “ the masses ”, shedding of responsibility, yet readiness to trade favours and succumb to corruption.
COVID has also exposed China’ s broken medical system. This is not news to anyone who pays attention to China, but it’ s educational to see how the malfunctions play out in such detail. Politics overrides science. Li and his colleagues were interrogated and punished for telling the truth, forced to make official “ confessions ”. Then, when Li’ s warnings proved correct and went viral on social media, he was exonerated posthumously by the authorities, who declared him a national hero in order to placate the Wuhan residents’ anger.
As becomes clear in the book, doctors and nurses in small hospitals earn paltry monthly salaries – less than even poor migrant factory workers. They also need to toe the Party line. As an example, hospitals, all under Party management, were instructed to falsify their statistics in order to shrink the infection and death rates, so as to satisfy the national authorities’ policy of keeping those rates low.
Since deaths outside hospitals were deliberately not recorded, isolation wards were emptied of dying patients by sending them home, infecting their own families. A doctor lamented there was nothing he could do to prevent this. When the virus was partially under control, even though people were still lining up to get into hospitals, the Wuhan authorities celebrated the Party’ s conquest of the virus with great fanfare.
A woman who would not be coaxed into accepting monetary compensation for the death of her daughter made a scene on the streets, marching with her daughter’ s portrait and crying for justice. She received a phone call from the police in no time, telling her not to “ publish sensitive remarks online ” because this “ would have a negative influence on the country … you must be vigilant against hostile anti-China forces. Don’ t let them use you. ” She finally acquiesced, after being put under surveillance for several months.
These are sad stories documenting Kafkaesque experiences of ordinary Chinese people. Sadder still is that the others – except for Zhang Zhan, who refused to stop calling out the lies – either lament their bad fate, or halfheartedly ( or wholeheartedly) accept the Party’ s propaganda. Domestic social stability and national security trump all other concerns. | business |
Meet CISA: US Critical Infrastructure’ s Cyber War General | Federal support for critical infrastructure cybersecurity is more important than ever in these heightened times of the Ukraine-Russia conflict. There is growing concern Russia will engage in cyber-attacks targeting western critical infrastructure assets as retaliation for political interference. The United States private sector relies on the Department of Homeland Security’ s Cybersecurity and Infrastructure Agency ( CISA) for the latest best practices, intelligence, and collaboration tools. This article serves as an introduction to CISA’ s important role in supporting the nation’ s critical infrastructure sectors.
Vladimir Putin’ s invasion of Ukraine on February 24, 2022, has no end or resolution in sight. The West has imposed sanctions to limit Putin’ s ability to access Russia’ s $ 630B war chest. There is growing concern Russia will conduct retaliatory cyber-attacks on the US and other western countries for interfering with the invasion.
Many European and US-based businesses have already suspended operations in Russia and the list continues to grow every day.
Russia has a history of engaging in destructive cyber-attacks targeting critical infrastructure such as Ukraine’ s power grid in 2015 and 2016. And in 2017, malware called Not Petya was unleashed on Ukraine’ s financial sector, spreading to millions of computers all over the world, disrupting supply chain operations of global companies such as FedEx and Maersk. Events of 2021 such as the SolarWinds breach as well as the ransomware attacks on Colonial Pipeline and JBS have been attributed to Russia as well.
This is NotPetya’ s ransom note displayed on a compromised system. The malware was designed to spread quickly, and that it had been targeting “ complete energy companies, the power grid, bus stations, gas stations, the airport, and banks ” according to Kaspersky.
Last year’ s disruptions in the supply of gasoline, meat, and beer emphasized the fragility of US critical infrastructure. Ransomware attacks continue to be an appealing attack vector for nation-state cybercriminals. Business leaders continue to ask the question, “ What if a Colonial-type event happened to us? ” Critical concerns include:
Immediate disruption of goods and services are devastating and have often resulted in an accelerated ransom payment. And to make matters more dire, the impacts of these types of cyber-attacks can lead to a humanitarian crisis and even death. Because victims pay ransom in Bitcoin and other forms of cryptocurrency, cybercriminals and their sponsors can bypass traditional monetary exchanges and ignore restrictions imposed by financial sanctions.
The notion a nation-state like Russia may resort to cyber-attacks was emphasized on March 21st, 2022, by a statement from President Biden on the nation’ s cybersecurity. The statement urges United States private sector partners to harden their cyber defenses immediately and leverage best practices that were developed in partnership with the Department of Homeland Security’ s Cybersecurity and Infrastructure Agency ( CISA).
Protecting critical infrastructure deserves the highest level of attention on the federal level. Given rapid monetary inflation, a broken supply chain, and a healthcare sector tested to its limits by the COVID19 pandemic, the last thing the US needs is more logistical disruption.
A Closer Look at How CISA Came to Be CISA is a federal agency within the Department of Homeland Security ( DHS) and was established on November 16, 2018, when President Donald Trump signed into law the Cybersecurity and Infrastructure Security Agency Act of 2018.
According to CISA’ s website their mission is to “ build the national capacity to defend against cyber-attacks ” and to work “ with the federal government to provide cybersecurity tools, incident response services and assessment capabilities to safeguard the.gov networks that support the essential operations of partner departments and agencies. ”
CISA connects stakeholders in public and private industry and government to each other and to resources, analyses, and tools to help them build their own cyber, communications, and physical security and resilience, in turn helping to ensure a secure and resilient infrastructure for the American people.
Before the Cybersecurity and Infrastructure Security Agency Act of 2018, federal cybersecurity responsibility was housed within the DHS but under National Protection and Programs Directorate ( NPPD). The 2108 legislation elevated the importance of critical infrastructure cybersecurity to its very own federal agency with its own budget- a huge public relations win.
Even though CISA was formally established in 2018, there has long been a desire to develop a framework to prioritize the most critical infrastructure entities so stronger cybersecurity could be codified into law and subsequent federal support could be better managed.
In 2013, the Obama administration issued Executive Order 13636 which attempted to identify the “ critical of critical. ” The administration issued this order recognizing the risk of cyber-attacks “ continues to grow and represents one of the most serious national security challenges we must confront. ”
Section 9 of the Executive Order focuses on companies rather than systems and assets. There has been discussion about this language, and the reasoning behind it. Many believe that it’ s easier to identify companies in possession of companies of critical systems rather than vice versa.
Unfortunately, Section 9 exempted the Information Technology sector, which proved to be a huge shortcoming in December 2020 during the SolarWinds hack. Many of SolarWinds clients were Federal entities and it is now obvious IT Sector is truly critical to national security as well public health, safety, and economic stability.
CISA is complex, with a multi-billion dollar budget and many initiatives impossible to cover in this brief article. However, in general terms, CISA is divided into two chief centers to achieve its mission. The first is the National Cybersecurity and Communications Integration Center ( NCCIC). It provides 24 x 7 cyber situational awareness, analysis, incident response and cyber-defense capabilities to the federal government, other US jurisdictions, the private sector, and international partners. The other chief center is the National Risk Management Center ( NRMC). It’ s a planning, analysis and collaboration center working to identify and address the most significant risks to the nation’ s critical infrastructure.
The NRMCC is more proactive and forward thinking and is critical for building a smarter and more resilient critical infrastructure. Here at Axio, we focus on these exact initiatives and will always believe and evangelize the importance of understanding and prioritizing your cyber risks so you can focus on the initiatives that matter most. It’ s the motivation behind our desire to build the Axio360 platform, which takes an integrated approach to cyber risk. Think of it as a checklist ( to assess your cybersecurity maturity), a calculator ( for you to quantify your exposure), and a magnifying glass ( to truly see what initiatives will matter most).
The truth is, you’ re going to get breached no matter what you do. Instead of guessing what cybersecurity initiatives will provide the most protection, prioritize with confidence.
CISA divides the nation’ s critical infrastructure into 16 Sectors. The 16 sectors are: Chemical, Commercial Facilities, Communications, Critical Manufacturing, Dams, Defense Industrial Base, Emergency Services, Energy, Financial Services, Food and Agriculture, Government Facilities, Healthcare and Public Health, Information Technology, Nuclear Reactors, Materials and Waste, Transportation Systems, and Water and Wastewater.
These 16 sectors have “ assets, systems, and networks whether physical or virtual so vital to the United States that their incapacitation or destruction would have a debilitating effect on security, national economic security, national public health or safety, or any combination thereof. ”
Having a federal agency with its own budget dedicated to critical infrastructure cybersecurity was a huge milestone for critical infrastructure owners and operators. However, the strategic direction and initiatives took time to get off the ground due to the sheer size and scope of CISA’ s mission and lack of awareness and “ brand recognition. ”
The attack on Colonial Pipeline on May 6, 2021, made cybersecurity a mainstream news headline for many weeks and greatly accelerated the need for a federal response. Early in his term, President Biden made critical infrastructure cybersecurity a priority of the Department of Homeland Security ( DHS) and reiterated the necessity for federal support.
On May 12, 2021, the President signed an Executive Order to improve the nation’ s cybersecurity and protect federal government networks.
Most of the actions outlined in the Executive Order are to be implemented by CISA.
In the summer of 2021, Axio was proud of doing our small part in opening a necessary dialogue to protect electricity operations from increasing cyber threats. On July 7th-8th 2021, we hosted the Energy Cybersecurity Insurance Forum. This was part of a 100-day plan formalizing the Industrial Control Systems Cybersecurity Initiative. It was coordinated between the Department of Energy ( DOE), the electricity industry and CISA. You can read the summary report here.
Senior administration officials said the 100-day plan has already led to over 150 electricity utilities representing almost 90 million residential customers deploying or agreeing to deploy control system cybersecurity technologies.
By the end of July, the Biden Administration signed the National Security Memorandum ( NSM) on “ Improving Cybersecurity for Critical Infrastructure Control Systems ” which ordered CISA and the National Institute of Standards and Technology ( NIST) to create benchmarks for organizations managing critical infrastructure.
New pilot plans like the 100-day initiative for electricity are in progress, with natural gas pipelines being next, followed by water systems, wastewater, and then the chemical sector. We envision CISA to play an important role in facilitating better information sharing and forward-thinking guidance and best practices.
With the first quarter of 2022 in the books, CISA’ s Executive Assistant Director for Cybersecurity Eric Goldstein outlined four top priorities for the year and beyond. Summarized, they are:
Critical Infrastructure needs to be protected from cyber threats at all costs. With nation-states like Russia now posing as cyber-public enemy number one, a risk-based approach to cybersecurity is more poignant than ever. Cyber physical attacks are a major concern necessary to address now. According to Gartner, cyber attackers will have weaponized operational technology environments to harm or kill humans. This shifts the term cyber war to a marketing term to a real and present danger. We already witnessed a foreshadowing, with potential poisoning of the Oldsmar, Florida water supply. This is just one of many examples. CISA is rapidly working with various public and private entities to facilitate the necessary awareness, trust, and collaboration in this new era of cyber warfare. It’ s a challenging endeavor given the sheer size of the many critical infrastructure sectors ( such as water and wastewater) and the systems and assets they are responsible for. CISA has prudently taken a risk-based approach to cybersecurity, understanding that defend-all is not as important as defending what matters. With the many new cybersecurity initiatives spearheaded by the current administration, we see a bright future for protection of critical infrastructure. In subsequent posts, we’ ll dive into the various sectors of critical infrastructure, highlighting various risk scenarios and areas of concern for owners-operators. After all, Axio is a quant company taking a risk-based approach to cybersecurity so you can be calm when the storm happens. When you know your security gaps and how much you have at stake, you can better plan the necessary cyber protection and ensure you survive.
In this post we discussed cyber risk quantification. If you are curious about our unique methodology, please don’ t hesitate to book a demo.
* * * This is a Security Bloggers Network syndicated blog from Axio authored by Axio. Read the original post at: https: //axio.com/insights/meet-cisa-us-critical-infrastructures-cyber-war-general/ | general |
More contagious omicron BA.2 is on track to displace others in U.S. | The more contagious omicron BA.2 subvariant now makes up 72% of Covid infections that have undergone genetic sequencing in the U.S., according to data from the Centers for Disease Control and Prevention.
BA.2 became dominant in the U.S. last week, and now appears on track to displace the earlier version of omicron, BA.1. Ali Mokdad, an epidemiologist at the Institute for Health Metrics and Evaluation in Washington state, projected that will happen within the next two weeks.
Though some estimates differ, BA.2 spreads 30% to 80% faster than BA.1., according to data from public health authorities in the U.K. and Denmark.
A top World Health Organization official, Maria Van Kerkhove, has described BA.2 as the most transmissible version of the virus so far. Renewed outbreaks have occurred in major European nations, including the U.K. and Germany.
Here in the U.S., though, White House chief medial advisor Dr. Anthony Fauci has said infections might rise, but he doesn't expect another major surge. Mokdad said he believes infections in the U.S. will likely level off for a week or two and then decline until winter.
In the U.S., new infections and hospital admissions have declined more than 90% since the peak of the omicron wave in January. The average number of people hospitalized with Covid in the U.S. was 11,000 as of Monday, the lowest level since 2020, according to data from the federal Health and Human Services Department. The U.S. reported a seven-day average of about 28,000 new infections on Sunday, the lowest level since last July, according to data from Johns Hopkins University.
BA.2 generally does not make people sicker than the earlier version of omicron, and the vaccines have the same level of effectiveness against it, according to studies from South Africa and Qatar. However, omicron in general is adept at evading the protective antibodies generated by the vaccines and causing breakthrough infections that normally cause mild illness.
Read CNBC's latest global coverage of the Covid pandemic: | business |
Regulator revokes licenses of financially troubled insurers | BI’ s Article search uses Boolean search capabilities. If you are not familiar with these principles, here are some quick tips.
To search specifically for more than one word, put the search term in quotation marks. For example, “ workers compensation ”. This will limit your search to that combination of words.
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Thailand’ s Office of Insurance Commission has revoked the business licenses of troubled nonlife insurers Southeast Insurance Co. Ltd. and Thai Insurance PLC effective April 1 after they failed to pay more than 18 billion Thai baht ( $ 538 million) worth of COVID-19 related claims, Asia Insurance Review reported citing The Nation. The OIC may take legal action against the executives of both the companies over delayed payouts and their failure to create sufficient reserves to cover the liabilities.
1. Regulator revokes licenses of financially troubled insurers
2. Axa won’ t appeal landmark COVID-19 BI ruling
3. Brokers calls for mandatory insurance for all buildings
4. Hardening market to go on longer than anticipated: Howden
5. Insurers settle $ 20.5 million claims related to plane crash
6. Insurance market hardening slows down, but concerns remain | general |
Daily Podcast: Hotel Hiring Improves | Get exclusive stories and unlimited access to Skift.com news
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Rashaad Jorden, Skift
April 4th, 2022 at 6:47 AM EDT
Good morning from Skift. It's Monday, April 4, in New York City. Here's what you need to know about the business of travel today.
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Today’ s edition of Skift’ s daily podcast discusses the improving employment numbers at U.S. hotels last month, Thailand’ s tourism strategy, and Delta’ s loyalty gift to leisure travelers.
U.S. hotels recorded solid job growth numbers in March, but industry executives are still grappling with a labor shortage amidst an expected boom in summer travel, writes Contributor May Ann Ha.
The accommodation sector added 23,000 jobs last month, according to the U.S. jobs report released on Friday by the U.S. Bureau of Labor Statistics. The leisure and hospitality sector, which includes hotels, represented about a quarter of the roughly 430,000 jobs the U.S. added in March.
However, employment in the sector is still down close to 9 percent from February 2020, and the hotel industry will likely struggle to hire enough workers in time for the busy summer season. David Leser, CEO of consulting firm LW Hospitality Advisors, said he doesn’ t see the challenges hotels face going away anytime soon.
We go to Southeast Asia next. The region’ s tourism industry received a major boost when countries such as Cambodia and Vietnam reopened in recent months to fully vaccinated international travelers with no quarantine requirements. However, Thailand — its most popular tourist destination — is taking a cautious approach in reopening that could hurt its recovery, writes Asia Editor Peden Doma Bhutia.
Foreign visitors arriving in Thailand under any of the country’ s three entry schemes will be allowed to enter without proof of a negative PCR test from April 1. However, all arrivals must have musical insurance covering health costs over $ 20,000 and register for the online Thailand Pass, regardless of vaccination status. In addition, visitors are required to take a Covid test on the first and fifth days of their stay in the country.
Those Covid protocols could deter some travelers from visiting Thailand. A Tourism Council of Thailand poll of 200 international travelers this year found that 71 percent of respondents found the process around the PCR tests on arrival cumbersome.
We end today with Delta Air Lines. The Atlanta-based carrier has made a tweak to its mileage program to provide more benefits to leisure travelers, who were instrumental in its rebound, reports Contributor Ted Reed.
Delta announced last week that it would remain the only U.S. carrier to grant status to travelers paying for flights with accumulated miles, making permanent a policy it introduced during the pandemic. Prashant Sharma, Delta’ s vice president of loyalty, said the company extended the policy to reward leisure travelers who contributed mightily to its recovery by using miles. The extension took effect on March 31. | general |
Benzene contract prices in the Atlantic Basin increase markedly for April | Our website uses cookies to ensure that we give you the best experience on our website. If you continue we 'll assume that you are happy to receive all cookies on the Argus Media website.
The monthly contract prices ( CP) for benzene in both Europe and the US both settled strongly higher for April as crude prices rallied higher during the respective CP windows.
In Europe, the April CP rose by $ 137/t to $ 1,263/t, the highest since June 2021. In euro terms, it increased by €131/t to €1,135/t. The conversion was based on the ECB reference rate of $ 1.1126/€1, against the $ 1.1216/€1 used in the March CP settlement.
In the US, the monthly contract price ( CP) settled higher for the sixth consecutive month at 409¢/USG ( $ 1,224/t). This represents a 31¢/USG ( $ 93/t) increase from the March price, and is the highest settlement since May 2021. The six-month rally has added an aggregate 107¢/USG ( $ 320/t) to the price since the October 2021 settlement.
It comes as little consolation to the derivative markets which consume benzene, but the settlements could have been even higher as crude prices have retreated during the last few days of March with North Sea Dated crude falling from $ 124/bl to $ 115/t by 30 March, and WTI cash prices in Houston peaking close to $ 118/bl during the window but falling to below $ 109/bl by 30 March.
Indeed, it is also very clear that benzene prices have not risen to anything close to the full extent that recent rises in crude prices would indicate. Since the beginning of the year, the ratios between benzene and crude prices have dropped from what might be considered as close to “ normal ” around 1.9 down to levels below 1.5, similar to those seen as the industry was still recovering from fall-out of the first wave of the COVID-19 pandemic in spring 2020.
For the derivative industries, these relentless price increases also come at a time when many have been struggling with other feedstock and energy price increases, supply chain challenges, extensive maintenance and repair activity but exceedingly strong order books.
The benzene buyers might well point out that benzene supply-demand balances are certainly far from tight, but the crude price “ lifts all boats ”, and benzene is no exception.
In fact, benzene recovery and conversion margins have been markedly compressed over recent months, with the benzene-naphtha spread in Europe falling more than half since January to just $ 172/t in March, and the benzene-gasoline spread in the US dropping by 50pc from 115¢/USG in December to just 57¢/USG in March.
The April Argus European monthly methanol contract price ( CP) was assessed at €567.5/t 30 March 2022, up by €72.5/t from €495/t in March.
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Scientists Uncover Why Long COVID Can Cause Pain – Could Lead to New Pain Medicine | Animal study reveals pain-associated gene expression signature that remains after infection clears; findings could lead to new pain treatments.
A new animal study has provided important insights into how COVID-19 SARS-CoV-2 — the virus responsible for COVID-19 — can lead to long-term pain. The new findings also point to a potential therapy for COVID-related pain.
“ A significant number of people suffering from long COVID experience sensory abnormalities, including various forms of pain, ” said Randal ( Alex) Serafini, an MD/PhD candidate from the Icahn School of Medicine at Mount Sinai in New York City. “ We used RNA sequencing to get a snapshot of the biochemical changes SARS-CoV-2 triggers in a pain-transmitting structure called dorsal root ganglia. ”
Using a hamster model of SARS-CoV-2 infection, the researchers found that infection left a gene expression signature in the dorsal root ganglia that remained even after the virus cleared. The signature matched gene expression patterns seen in pain caused by other conditions.
Serafini will present the new research at the American Society for Pharmacology and Experimental Therapeutics annual meeting during the Experimental Biology ( EB) 2022 meeting, to be held April 2–5 in Philadelphia.
This research was led by Alex Serafini ( middle photo, left) and Justin Frere ( middle photo, right) under the mentorship of Venetia Zachariou from the Icahn School of Medicine at Mount Sinai ( left) and Benjamin tenOever from New York University ( right). Credit: Alex Serafini, Icahn School of Medicine at Mount Sinai
“ Our findings could potentially lead to new therapies for patients suffering from acute and long COVID, as well as other pain conditions, ” said Serafini. “ Our study also shows that SARS-CoV-2 causes long-term effects on the body in drastically new ways, further underscoring why people should try to avoid being infected. ”
The experiments involved a hamster model of intranasal COVID-19 infection that closely reflects symptoms experienced by people. The researchers observed that SARS-CoV-2-infected hamsters showed a slight hypersensitivity to touch early after infection, which became more severe over time, up to 30 days. They then performed similar experiments with the Influenza A virus to determine if other RNA viruses promote similar responses.
In contrast to SARS-CoV-2, Influenza A caused an early hypersensitivity that was more severe but faded by four days post-infection. Analysis of gene expression patterns in the dorsal root ganglia revealed that SARS-CoV-2 caused a more prominent change in expression levels of genes implicated in neuron-specific signaling processes compared to influenza.
Additional experiments showed that four weeks after recovering from viral infection, flu-infected hamsters had no signs of long-term hypersensitivity while SARS-CoV-2-infected hamsters showed worsened hypersensitivity, reflecting chronic pain. The hamsters that had recovered from SARS-CoV-2 had gene expression signatures similar to those seen in the dorsal root ganglia of mice affected by pain that was induced by inflammation or nerve injury.
To dive deeper into the molecular machinery associated with altered sensation in SARS-CoV-2-infected infected hamsters, the researchers applied bioinformatic analyses to the gene expression data they had obtained. The analysis predicted that SARS-CoV-2 downregulates the activity of several previously identified pain regulators and a protein called interleukin enhancer binding factor 3 ( ILF3).
This downregulation occurs at times when pain behaviors in SARS-CoV-2-infected hamsters were very mild, despite heavy systemic inflammation. In contrast, Influenza A-induced hypersensitivity was severe at these timepoints. ILF3 has not yet been studied in the context of pain but is a potent cancer regulator.
Based on these findings, the researchers hypothesized that mimicking the acute effects of ILF3 could serve as a new pain treatment strategy. To test this prediction, the researchers administered a clinically tested anti-cancer drug that inhibits ILF3 activity. They found that it was indeed very effective at treating pain in a mouse model of localized inflammation.
“ We think therapeutic candidates derived from our gene expression data, such as ILF3 inhibitors, could potentially target pain mechanisms that are specific to COVID patients, both acutely and chronically, ” said Serafini. “ Interestingly, we saw a few cancer-associated proteins come up as predicted pain targets, which is exciting because many drugs have already been developed to act against some of these proteins and have been clinically tested. If we can repurpose these drugs, it could drastically cut down therapeutic development timeline. ”
The researchers are working to identify other compounds that could be repurposed while also keeping an eye out for novel compounds that might inhibit ILF3 activity.
This research was led by Alex Serafini and Justin Frere, MD/PhD candidates from the Icahn School of Medicine at Mount Sinai. Serafini is a student of Venetia Zachariou, PhD, professor of neuroscience at Mount Sinai and Frere is a student of Benjamin tenOever, PhD, professor of microbiology at New York University.
Randal ( Alex) Serafini will present this research from 10 a.m.–12 p.m., Monday, April 4, in Exhibit/Poster Hall A-B, Pennsylvania Convention Center ( Poster Board Number B24) ( abstract) and 2:18–2:27 p.m., Tuesday, April 5, in Room 113 C ( abstract). Contact the media team for more information or to obtain a free press pass to attend the meeting. | tech |
Clarity, Agility, Reliability, and Simplicity: 4-step guide for operational resilience | Is your business resilient? It’ s a simple question, and many of us would like to answer with a simple yes. However, it’ s the unfortunate case that many aren’ t. Regulators are increasingly focusing on resiliency. These firms must ensure their businesses are able to prevent, adapt, and respond to any and all outside disruptions. This includes being able to quickly recover and respond to sudden changes. The disruption caused by COVID-19 has displayed why it is critical for firms to invest in their resiliency to protect themselves, their consumers, and the financial system. To ensure that companies are operationally resilient, regulatory bodies governing the financial services of the UK have united to introduce a new Operational Resilience Policy. Coming into effect on March 31st, 2022, the policy will address operational risk management, business continuity planning, and the management of outsourced relationships. Firms will be given a three-year transition period until March 2025. During this time, they are expected to continue business mapping and scenario testing to ensure they can comply with policy guidelines long term. Resiliency is not a destination, it’ s a way of being. Even small changes can contribute towards a stronger tomorrow. Now is the best time to do something to ensure your firm is resilient. But how can this be achieved? It all comes down to bringing together cross-functional teams across your institution to collaborate and improve your organisation’ s clarity, agility, reliability, and simplicity. 1. Clarity To be as resilient as possible, financial leaders must be able to identify the biggest risks to their organisations. The more clarity and visibility decision-makers have over their business operations, the better the quality and overall business performance. Having a clear view of processes across the enterprise is key for financial leaders, and is one of the main indicators that the correct procedures are being followed. Having a lack of clarity leads to delayed decisions and costly mistakes. This was especially vital at the start of the pandemic when financial companies were blindsided by the dramatic change in the financial landscape and the push to digitalise. 2. Agility Being agile is no longer a ‘ nice to have’. It is a necessity. Ultimately, agility is a competitive advantage as banks continue to face more uncertainty and complexity. For example, FinTech startups are disrupting the market and encouraging traditional financial organisations to step up and adapt quickly. The ability to respond quickly to change is now becoming the hallmark of highly digitised organisations as a result. With most companies operating remotely - at least in hybrid form - migrating systems to the cloud can help companies move at the speed their customers and employees demand. Moreover, cloud capabilities can simplify the process for organisations to quickly deploy and scale new solutions. 3. Reliability While reliability should be a given, it is difficult to achieve. Especially as we consider the complex environments we must work in: whether hybrid, on-premise, or a combination of the two. To achieve consistency and quality results time after time, financial firms must ensure that they have the right operations and business processes in place. By allowing companies to map out their operational frameworks in detail, business leaders can make sure they are dependable. In situations where this is not possible, it’ s crucial that organisations can detect failure and respond to it swiftly. After all, the enterprise IT landscape has changed significantly in recent times, so outdated technology systems that take a long time to adapt to new innovations can not cope in this environment. Building systems that are reliable, no matter what changes we may see, is critical now. 4. Simplicity The final step is to ensure your organisation has a smooth and easy process in place for making business decisions. Simplicity requires a firm to have focus and a defined decision-making procedure for business leaders which is straightforward, intuitive, and unambiguous. Smooth business decision systems are key when companies are making business continuity plans for the future. This helps to ensure that in the case of a severe business disruption, the firm is able to operate on an ongoing basis with limited losses. The bottom line This exciting new policy challenges financial institutions to change how they operate, leading to better decision-making, collaboration, and insights. Firms currently going through this change might feel a little overwhelmed, but the four principles mentioned above can help guide and shape this journey. Operational resiliency is vital for the financial sector to be as forward-thinking as possible. It is crucial when putting adequate contingency and business continuity plans in place, and in allowing swift responses to any outside disruptions. As the UK’ s Operational Resilience Policy draws closer, we’ re going to see banks make a step-change in their processes. Keeping clarity, agility, reliability and simplicity front of mind will be critical in doing so.
1360 | tech |
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Restructuring Liberty Steel Group's Liege unit in Belgium has recently become `` much more complex '' due to escalating energy and carbon prices and geopolitics, according to a Liberty Steel spokesperson.
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Liberty Steel's Flemalle steel galvanizing lines in Belgium -- part of the Liege unit -- have remained at a standstill since December 2021 due to lack of feedstock and the ongoing restructuring process, market sources and sources close to the company told S & P Global Commodity Insights April 1 and 4.
A court decision on a business plan presented to ensure the plant's future is expected April 13, a Liberty Steel Group spokesperson said.
One market source indicated that doubts have grown over an eventual restart at the galvanizing installations. This follows a meeting between the company and the Liège Enterprise Court last week.
`` At a meeting with the Liège Enterprise Court on 30 March, the management of LIBERTY Liège gave a detailed presentation on the company's significant restructuring process and explained that it had been made much more complex due to the huge rise in energy and carbon prices over the last few months, supply shortages due recent geopolitical developments as well as excessive competition from imports into Europe, '' a Liberty Steel Group spokesperson said in a note emailed to S & P Global over the weekend.
`` Despite that, LIBERTY Liege has made good progress on its new business plan, which will support the sustainable future of the business, and remains committed to delivering the investment required to secure that future. ''
Details of the business plan were not given due to their `` commercially sensitive '' nature.
`` LIBERTY Liège calls on its stakeholders to support the business plan submitted to the court as it will avoid potential disruption of production, '' the spokesperson continued. `` The company now awaits the Court's decision on 13 April which we hope will support the new business plan, which offers the best chance for a sustainable outcome for the plants, their 650 employees and their loyal customer base. ''
The Liberty Steel spokesperson confirmed that production restarted as planned and announced mid-February at the 200,000 mt/year tinning line at its Tilleur site in Belgium, also part of Liberty Liege. This restart followed three months of maintenance work on this line and intermittent disruption in raw material supplies amid the coronavirus pandemic.
GFG Alliance, which groups together Liberty Steel Group and other metals and energy assets owned by magnate Sanjeev Gupta, had provided more than Eur40 million ( $ 47 million) in funding to Liberty Liège since its acquisition from ArcelorMittal as part of an anti-trust deal in July 2019, Liberty Steel Group said in February. However, the investment plans were initially undermined by a weak steel market in 2019, before the business was negatively impacted by the pandemic and supply chain disruptions, followed by the collapse of Greensill Capital, GFG Alliance's main financier, in March 2021.
Flemalle has two galvanizing lines: G4 and G5. Liberty Steel Group had previously said it had a `` commitment '' to the Liège authorities to restart the G5 plant.
Liberty's intended restructuring of Liberty Liège follows the earlier granting of court protection from creditors – under a so-called judicial reorganization procedure requested in April 2021 - for both its Liège and Dudelange operations.
As part of a broader group restructuring announced late June 2021, Liberty Group merged its Liege, Dudelange in Luxembourg and Magona steel works in Italy into its larger Galati integrated steel operation in Romania.
Dudelange and Liege together have annual production capacities estimated at 1.6 million mt of galvanized/coated steel, 300,000 mt of cold-rolled coil, and 200,000 mt of tinplate, products sought after in recent months due to a tightness in European markets.
Magona restarted its cold rolled coil and hot dip galvanized lines in August 2021, using hot rolled coil supplied by Galati. Market sources have indicated that the need for galvanized material from Liège's G4 line may now be less given Magona's ramp-up.
Local press speculated last September that one galvanizing line at Flemalle could be mothballed, amid redundancies.
Platts North European hot-dip galvanized coil domestic ex-works price rose to a high of Eur1,550/mt ( $ 1,699/mt) March 23, before slipping back marginally last week. Price of the product, used in the automotive, white goods and construction sectors, has risen 40% year-to-date.
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UK banks ' buyback plans face risks from prolonged Russia-Ukraine war | Russia's invasion of Ukraine could impact the largest U.K. banks ' planned share buybacks if it exacerbates risks in the economy.
HSBC Holdings PLC and Standard Chartered PLC plan to buy back shares of up to $ 1 billion and $ 750 million, respectively, in 2022, while Lloyds Banking Group PLC and NatWest Group PLC announced repurchase programs of as much as £2 billion and £750 million, respectively. Barclays PLC also intends to repurchase up to £1 billion of shares, although the bank recently decided to delay its launch to the second quarter due to a bond sale error.
While none of the banks has so far disclosed any material direct exposure to Russia and Ukraine, they could experience second-order effects from the war caused by increasing risks in the economy, Morningstar equity analyst Niklas Kammer told S & P Global Market Intelligence.
`` Future earnings and [ capital ] distributions will clearly depend on how the conflict ultimately affects the economy, '' a spokesperson for NatWest told Market Intelligence in response to emailed questions. Higher energy prices, supply chain disruption and higher inflation are likely to be the predominant factors that would impact customers and the economy, the spokesperson said, noting that these may aggravate the situation depending on the extent and duration of the conflict.
Scope Ratings would also be looking at how a weaker operating environment could impact the U.K. banks ' earnings and, consequently, their ability to distribute capital.
`` There may be spillover effects as the economic recovery is less robust, '' Pauline Lambert, executive director of financial institutions ratings at Scope, told Market Intelligence. Revenue generation would also be impacted by weaker consumer confidence and disrupted capital markets, while credit costs could rise if the banks ' customers are impacted by the conflict, Lambert said.
The five biggest U.K. banks also declared final dividends on 2021 results, and Scope expects them to stick with the planned payouts as they showed a solid performance last year. But compared with dividends, share buybacks by nature are more flexible, Scope's Lambert said. As such, the ongoing war could put a damper on buyback plans if deemed appropriate by the banks ' management teams.
NatWest and StanChart have not made any changes to their planned distributions, both banks told Market Intelligence. HSBC, Barclays and Lloyds did not respond to requests for comment.
`` The announced distributions should be paid out, '' Kammer said. `` Unless the regulator blocks payments again, which we think is not likely at the moment, we do not see a reason why the banks would not follow through with their current distribution plans, '' Kammer said. He was referring to the Bank of England's decision at the onset of the COVID-19 pandemic in 2020 to restrict banks from paying dividends and repurchasing shares to preserve capital and continue lending to the economy. The restrictions were lifted in 2021.
The banks ' buyback plans, which were announced on the back of a year-over-year rebound in the banks ' profits and high capital levels in 2021, all exceeded consensus expectations, according to a March 1 research note from Berenberg.
At the end of 2021, the respective common equity Tier 1 ratios — a measure of financial strength — of HSBC and Barclays stood at 15.74% and 14.74%, while those of StanChart, Lloyds and NatWest were 14.05%, 16.86% and 17.83%, according to Market Intelligence data.
`` We do not expect the war in Ukraine to affect [ the ] banks ' capital levels and/or CET1 ratio targets, '' Kammer said.
The banks ' `` exceptional '' performance in 2021 was mainly driven by releases in loan loss provisions — funds set aside to cover future loan losses — as they took significant steps to bolster their provisioning in 2020 after the COVID-19 pandemic struck, S & P Global Ratings said in a March 3 report.
StanChart did not book a release in impairment but recorded a sharp decline in charges on a yearly basis, to $ 254 million from $ 2.33 billion.
The banks ' results showed their resilience amid the pandemic and they are expected to deliver more of the same in 2022, Ratings said, while noting that there is a high degree of uncertainty about the extent, outcome and consequences of the Russia-Ukraine conflict.
Barclays has `` limited '' financial exposures to the conflict, CEO C.S. Venkatakrishnan told reporters on a call late February, according to Bloomberg News. The lender has been out of Russia for many years and `` exercised a lot of care and diligence '' in onboarding Russian entities and clients, Venkatakrishnan said.
While Barclays may have some trading exposure, there does not seem to be anything worrisome thus far in terms of capital, Morningstar's Kammer said.
For HSBC, CFO Ewen Stevenson told Bloomberg TV in February that the bank's `` very small business '' in Russia presents a `` very, very modest '' overall exposure.
StanChart has no operations in Russia or Ukraine, a spokesperson for the bank told Market Intelligence. Meanwhile, Lloyds and NatWest have no meaningful direct exposure to both countries, according to Kammer. | business |
Parliamentary group says regulators must adapt to post-pandemic working practices | It has found that the pandemic has directly driven the digital transition in both banking services and working practices.The APPG conducted its second periodic industry survey early in 2022. This anonymous research survey looked at how the coronavirus pandemic had impacted challenger banks and building societies as well as the actions of government, regulators, and customers had impacted smaller challenger institutions.Broadly speaking two thirds of institutions felt that the advice they had received from the regulator was helpful and clear. While just under a third through the opposite.71% felt that the regulatory community had provided helpful and clear advice, with only minority reporting that it was incomplete or vague. This compared favourably when compared to our 2020 findings.In terms of specific regulators, the PRA and the Bank of England came in for particular praise as did the UK Finance Trade Association. Of those who were critical, it was the FCA which bore their ire. However, even this was balanced by some very positive commentary around the FCA’ s work demonstrating that they had improved their response over the pandemic. It is interesting to compare this to the 2020 survey where respondents reported that the FCA had come in for especially with regard to its understanding of small firms.The survey received a strong response from a wide range of institutions across the sector and the results are detailed in the accompanying report. Based on its research the APPG for Challenger Banks and Building Societies has made the following recommendations:1 The regulatory community needs to adjust to the new realities of remote and flexible working. These have clearly become large features during the pandemic and in many ways may be here to stay. They will have a profound effect on both the experience of staff working for firms and customers accessing services; 2 The pandemic has resulted in a huge shift to digital transactions as more normal life returns Government and regulators need to make sure that vulnerable customers and those who depend on traditional cash-based transactions are not unduly disadvantaged; and,3 Government needs to adjust regulation where necessary to take account of pandemic changes to work patterns and business models.Commenting on the findings of this report, the Chair of the APPG on Challenger Banks and Building Societies, Rt. Hon Karen Bradley MP, commented: “ We were fascinated to see the change in perception towards the regulators compared to our 2020 work. There were criticisms from some, but overall firms seem far more satisfied with the Government and the regulators now than they were at the start of the pandemic. “ The pandemic has had a huge effect on businesses operationally and on working patterns across the economy. Although restrictions have now ended, it looks as if many of these effects from remote working to increased digital transactions will be permanent changes. “ It is the view of the APPG that Government and regulators need to be fleet of foot in monitoring the effect these have on our economy and on firms’ business practices and ensure their actions moving forward reflect these changes. ” | tech |
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