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To meet the specific education needs of ethics committee members (primarily full-time healthcare professionals), the Regional Ethics Department of Kaiser Permanente Northern California (KPNCAL) and Washington State University’s Elson Floyd School of Medicine have partnered to create a one-academic year Medical Ethics Certificate Program. The mission-driven nature of the KPNCAL-WSU’s Certificate Program was designed to be a low-cost, high-quality option for busy full-time practitioners who may not otherwise opt to pursue additional education.
This article discusses the specific competency-focused methodologies and pedagogies adopted, as well as how the Certificate Program made permanent changes in response to the global pandemic. This article also discusses in detail one of the Program’s signature features, its Practicum—an extensive simulated clinical ethics consultation placing students in the role of ethics consultant, facilitating a conflict between family members played by paid professional actors. This article concludes with survey data responses from Program alumni gathered as part of a quality study.
The beef industry is facing increasing pressure to adopt sustainable practices, driven by environmental, economic, and social concerns. Designing effective policies that satisfy industry demands while aligning with public interests is a complex challenge. Using a nationally representative survey of 3,001 U.S. residents, we employ a best–worst scaling approach to assess preferences for nine beef sustainability policies. Results reveal consumers prioritize affordability of beef products and welfare of cattle as most important sustainability policies. Conversely, policies addressing greenhouse gas emissions from cattle production are least important, with less than 6% of respondents preferring them.
To estimate the cost and affordability of healthy diets recommended by the 2016–2020 Vietnamese food-based dietary guidelines (FBDG).
Design:
Cross-sectional analysis. The Cost of a Healthy Diet (CoHD) indicator was used to estimate the lowest cost of healthy diets and compare the cost differences by food group, region and seasonality. The affordability of healthy diets was measured by further comparing the CoHD to food expenditures and incomes.
Setting:
Food prices of 176 food items from January 2016 to December 2020 were derived using data from monthly Consumer Price Index databases nationally and regionally.
Participants:
Food expenditures and incomes of participants from three latest Vietnam Household Living Standard Surveys were used.
Results:
The average CoHD between 2016 and 2020 in Vietnam was 3·08 international dollars using 2017 Purchasing Power Parity (24 070 Vietnamese Dongs). The nutrient-rich food groups, including protein-rich foods, vegetables, fruits and dairy, comprised approximately 80 % of the total CoHD in all regions, with dairy accounting for the largest proportion. Between 2016 and 2020, the cheapest form of a healthy diet was affordable for all high-income and upper-middle-income households but unaffordable for approximately 70 % of low-income households, where adherence to the Vietnamese FBDG can cost up to 70 % of their income.
Conclusions:
Interventions in local food systems must be implemented to reduce the cost of nutrient-rich foods to support the attainment of healthier diets in the Vietnamese population, especially for low-income households.
National regulatory authorities (NRAs) play a key role in energy transition from fossil fuels to renewable energy sources. A recent judgment of the Court of Justice of the European Union has clarified the requirements of NRA independence under European Union (EU) energy law. The Court classified the exclusive competence of NRAs to fix network tariffs as purely technical assessments of factual realities. This article challenges this assumption and examines whether the technical administrative tasks of NRAs can in fact be separated from political choices. It also explores the delineation of competences between NRAs and national governments at the EU and national levels, as exemplified by the Netherlands and by the proposed Dutch Energy Act.
Discusses both normative accounts for regulation (Why should we regulate?) and alternative accounts that attempt to explain the existence of regulation (Why do we regulate?)
Joan Costa-Font, London School of Economics and Political Science,Tony Hockley, London School of Economics and Political Science,Caroline Rudisill, University of South Carolina
This chapter goes over the decision to purchase health insurance (or not). The way information is presented to individuals has a significant impact on their decision to purchase insurance to protect themselves from the financial consequences of health risks. Eliminating minor inconvenience costs or simplifying the insurance selection process can influence whether or not people purchase insurance. This chapter examines the roles of adverse selection and moral hazard in insurance-related behaviour, as well as the barriers to insurance uptake for individuals ranging from affordability to unobservable quality and information/choice overload. The chapter investigates the role of various nudges in increasing health insurance uptake.
Food-based dietary guidelines promote consumption of a variety of nutritious foods for optimal health and prevention of chronic disease. However, adherence to these guidelines is challenging because of high food costs. The present study aimed to determine the nutrient density of foods relative to cost in South Africa, with the aim to identify foods within food groups with the best nutritional value per cost. A checklist of 116 food items was developed to record the type, unit, brand and cost of foods. Food prices were obtained from the websites of three national supermarkets and the average cost per 100 g edible portion was used to calculate cost per 100 kcal (418 kJ) for each food item. Nutrient content of the food items was obtained from the South African Food Composition Tables. Nutrient density was calculated using the Nutrient Rich Food (NRF9.3) Index. Nutrient density relative to cost was calculated as NRF9.3/price per 100 kcal. Vegetables and fruits had the highest NRF9.3 score and cost per 100 kcal. Overall, pulses had the highest nutritional value per cost. Fortified maizemeal porridge and bread had the best nutritional value per cost within the starchy food group. Foods with the least nutritional value per cost were fats, oils, foods high in fat and sugar, and foods and drinks high in sugar. Analysis of nutrient density and cost of foods can be used to develop tools to guide low-income consumers to make healthier food choices by identifying foods with the best nutritional value per cost.
Policies are the instrument that governments mobilize for carrying out their intentions to interfere in reality, transforming their vision for the development of the territories they encompass into reality, whether on a national, local or supralocal scale. Several definitions have been proposed for the concept, with the following being suitable for the purposes of this publication: “a process, which involves decisions on the part of governmental bodies and authorities, and actions, carried out by an actor or a group of actors, which consists of goals and the means to achieve them” (Heller & Castro, 2007).
A question frequently arises in the field of human rights as to why the rights do not become real, even when they are recognized in legal frameworks. More specifically, how to convert economic, social and cultural rights into concrete reality? Why do not the legal frameworks translate into equality, changing the circumstances of those living in vulnerable conditions? Or, more specifically, what are the conditions that favour or hinder the implementation of ESCR?
In most societies, many groups and individuals rely on places beyond the scope of the household to live and enjoy their rights, including their rights to water and sanitation. These groups include persons in penal institutions and detention centres, health care professionals and patients who spend long periods in hospitals and health centres, students in boarding schools and workers who are required to spend considerable lengths of time in open workplaces. They also include people who reside in those spheres because of homelessness, people living in poverty who may lack access to water and sanitation in or near their homes and people who work formally or informally in the public spaces of urban areas. More broadly, they include the general public who commute daily.
The debate around the international framework for HRtWS is permeated by challenges and endorsements from United Nations member states and civil society. Such a debate has implications both as to what precisely the content of the rights are and what the nature of countries’ obligations related to such rights is, as well as how these should be concretely realized in practical terms.
Inequalities based on gender exist basically in every country and in all aspects of social life, and are echoed in the vast divides between men and women in their ability to access, manage and benefit from water, sanitation and hygiene. A large and growing body of studies suggests that women and men often have differentiated access, use, experiences and knowledge of water, sanitation and hygiene. Cultural, social, economic and biological differences between women and men consistently lead to unequal opportunities for women in the enjoyment of the HRtWS, with devastating consequences for the enjoyment of other human rights and gender equality more generally.
This analysis of the human rights to safe drinking water and sanitation (HRtWS) uncovers why some groups around the world are still excluded from these rights. Léo Heller, former United Nations Special Rapporteur on the human rights to water and sanitation, draws on his own research in nine countries and reviews the theoretical, legal, and political issues involved. The first part presents the origins of the HRtWS, their legal and normative meanings and the debates surrounding them. Part II discusses the drivers, mainly external to the water and sanitation sector, that shape public policies and explain why individuals and groups are included in or excluded from access to services. In Part III, public policies guided by the realization of HRtWS are addressed. Part IV highlights populations and spheres of living that have been particularly neglected in efforts to promote access to services.
To provide a cross-country analysis of selection, availability, prices and affordability of essential medicines for mental health conditions, aiming to identify areas for improvement.
Methods
We used the World Health Organization (WHO) online repository of national essential medicines lists (EMLs) to extract information on the inclusion of essential psychotropic medicines within each country's EML. Data on psychotropic medicine availability, price and affordability were obtained from the Health Action International global database. Additional information on country availability, prices and affordability of essential medicines for mental disorders was identified by searching, up to January 2021, PubMed/Medline, CINAHIL, Scopus and the WHO Regional Databases. We summarised and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors, and by country income groups.
Results
A total of 112 national EMLs were analysed, and data on psychotropic medicine availability, price and affordability were obtained from 87 surveys. While some WHO essential psychotropic medicines, such as chlorpromazine, haloperidol, amitriptyline, carbamazepine and diazepam, were selected by most national lists, irrespective of the country income level, other essential medicines, such as risperidone or clozapine, were included by most national lists in high-income countries, but only by a minority of lists in low-income countries. Up to 40% of low-income countries did not include medicines that have been in the WHO list for decades, such as long-acting fluphenazine, lithium carbonate and clomipramine. The availability of generic and originator psychotropic medicines in the public sector was below 50% for all medicines, with low-income countries showing rates lower than the overall average. Analysis of price data revealed that procurement prices were lower than patient prices in the public sector, and medicines in the private sector were associated with the highest prices. In low-income countries, the average patient price for amitriptyline and fluoxetine was three times the international unit reference price, while the average patient price for diazepam was ten times the international unit reference price. Affordability was higher in the public than the private sector, and in high-income than low-income countries.
Conclusion
Access to medicines for mental health conditions is an ongoing challenge for health systems worldwide, and no countries can claim to be fully aligned with the general principle of providing full access to essential psychotropic medicines. Low availability and high costs are major barriers to the use of and adherence to essential psychotropic medicines, particularly in low-and middle-income countries.
The ability to appreciate and account for the magnitude and complexity of the interactions of efficiency and viability, on the one hand, and social concerns (including equity), on the other, continues to be a major regulatory challenges. One of the keys to effective targeting is to distinguish between lack of access and lack of affordability. For both challenges, regulators can rely on large menu of pricing, direct and cross-subsidies, technological or quality options or service obligations to reduce or eliminate the undesirable social biases. The optimal choice depends on the local preference, on the local fiscal capacity and on the implementation capacity of the regulators. And this requires a specific institutional diagnostic. Regulators should pay more attention to the costly default options often found in menus of service levels, and push for these to be reset so as to maximize the odds of helping those who need it most. To ensure that regulation delivers on the social goals to be addressed, regulators must make the most of the growing volume of data available and use it with more rigour to refine the social targeting efforts.
The environmental concern and its social side effects will be at the core of regulatory authorities’ agenda on top of short-term efficiency objectives in the foreseeable future. The steady growth of ‘big data’, of digitalization and of the new data-processing technologies will change the way firms and governments use and share information in the design, compliance and enforcement of regulation. The institutional environment of regulation will need to evolve to correct institutional mistakes of the past and to internalize the impact of the data revolution on the distribution of regulatory mandates across agencies and across sectors within countries and across countries. Non-traditional financial actors will press regulators to internalize more systematically financial markets’ concerns in the design of regulation in exchange for their willingness to help close the financing gap of many regulated industries. Keeping the right balance between the return-on-investment objectives of non-traditional financial actors, investment targets, users’ needs and taxpayers’ benefit is a challenge for the regulators of the future. Tools emerging from applied research in behavioural economics will offer new alternative regulatory tools to improve the effectiveness and targeting of regulation.
The federal Safe Drinking Water Act (SDWA), as amended in 1996, enables benefit-cost analysis (BCA) to be used in setting federal drinking water standards, known as MCLs. While BCAs are typically conceived of as a tool to inform efficiency considerations by helping to identify MCL options that maximize net social benefits, in this paper we also illustrate how important equity and affordability considerations can be brought to light by suitably applying BCAs to drinking water regulations, especially in the context of communities served by relatively small water systems. We examine the applicability and relevance of health-health analysis (HHA), and provide an empirical evaluation of the risk tradeoffs that may be associated with the MCL established for arsenic. We find that the cost-associated risks may offset a nontrivial portion of the cancer risk reduction benefits attributed to the MCL (e.g., the additional adverse health impacts from the costs may be roughly half as large as the number of cancer cases avoided). This reveals the relevance of using the HHA approach for examining net benefits of MCLs in small drinking water utilities, and raises issues related to whether and how these cost-associated health risks should be considered in BCAs for drinking water standards.
Affordable nutrition refers to the relation between nutrient density of foods and their monetary cost. There are limited data on affordable nutrition in low- and middle-income countries. The present study aimed to develop a nutrient density score and nutrient affordability metrics for 377 most consumed foods in Brazil.
Design:
The foods were aggregated into seven major food groups and four NOVA food categories. Nutrient composition data were obtained from the Brazilian Institute of Geography and Statistics. Food prices were obtained from retailer websites and were converted to prices per 100 g and 418 kJ. The Nutrient Rich Food (NRF8.2) score was based on protein, fiber, vitamins A, C and E, Ca, Fe and K. Nutrients to limit were sugar and Na. Affordability was measured as kcal/R$ and nutrients/R$.
Results:
Grains, fats and sweets were more energy dense and had lower NRF8.2 scores than dairy, vegetables and fruits. Grains, fats and sweets were the lowest cost sources of energy. Vegetables and fruits, beans, nuts and seeds and eggs and dairy were the lowest cost sources of multiple nutrients. Ultra-processed foods (48 % of total) had higher energy density and lower NRF8.2 scores than did unprocessed foods. In Brazil, fruits, vegetables and dairy products offered the most nutrients per real.
Conclusions:
Analysis of the relationship between nutrient density of foods and their cost can help identify locally available foods that are nutrient rich, affordable and culturally acceptable. Achieving high nutrient density at an affordable cost should be the goal of Brazil’s food systems.
United States Environmental Protection Agency (USEPA) has regulated drinking water since the 1974 Safe Drinking Water Act (SDWA). Congress directed it to achieve three conflicting goals: (i) establish stringent nationwide standards, (ii) ensure that these standards are both technologically and economically feasible, and (iii) accommodate significant differences in cost among water systems of different sizes with different water sources. USEPA chose to emphasize goal (i) at the expense of (ii) and (iii). In 1986, Congress intensified its preference for (i), was silent concerning goal (ii), and criticized USEPA for failing to achieve goal (iii). In lieu of economic feasibility, the Agency substituted “affordability,” defined as expenditures up to 2.5 % of national median household income irrespective of the benefits. This imposed deadweight losses, and substantial inequities on rural areas, low-income communities, and low-income households generally. In 1996, Congress directed USEPA to use benefit-cost analysis positively and normatively. Regulations issued since 1996 do not appear to comply, however. A review of post-1996 drinking water standards indicates that most were certified by USEPA as having benefits that justified costs, but these determinations were unsupported by the Agency’s own regulatory impact analyses. This article proposes that USEPA define by regulation that “economic feasibility” means marginal benefits exceed marginal costs for the smallest water system subject to SDWA, and that all future drinking water standards must be economically feasible. Economic efficiency would be greatly enhanced and the pervasive inequities of “affordability” greatly diminished. Unlike “affordability,” this definition is objective and compatible with lay intuition about the meaning of key regulatory terms.
The main objective was to assess the cost, acceptability and affordability of the Cypriot Diabetic Healthy Food Basket (DHFB).
Design:
The development of DHFB was based on the Cypriot HFB with adjustments based on the nutritional guidelines for diabetes as developed by the American Diabetes Association (ADA) and information retrieved through the questionnaires. Two DHFB were constructed for adult women and adult men (±40 years) diagnosed with diabetes. Affordability was defined as the cost of DHFB as a percentage of the Guaranteed Minimum Income (GMI).
Setting:
Cyprus.
Participants:
422 diabetic patients aged 18–87 years from different socioeconomic backgrounds.
Results:
DHFB consists of eight food categories, similar to Cypriot HFB, but different specific food items. The total monthly budget for a diabetic woman is about 15 % (25·68 Euros less) lower compared with HFB, and the relative percentage for a diabetic man is about 16 % (37·58 Euros less). The total monthly budget for a diabetic woman is about 30 % lower (60·32 Euros less) compared with that of a diabetic man. For low-income adults receiving GMI, the proportion of income that would need to be spent on DHFB ranges from around 30 to 42 % for women and men, respectively.
Conclusions:
The cost of DHFB is lower compared with HFB, meaning that nutritional treatment based on the practice guidelines for diabetes could be a cost-efficient therapy for these patients. DHFB is still not affordable among low-income persons.