Chapter 3.9 Explains how payment mechanisms should respond to the notion of antibiotics as global public goods. Global public goods are goods and services whose benefits are universal in scope. Antimicrobial resistance (AMR) poses a major health and economic threat world-wide, making novel antibiotics a global public good. Payment mechanisms have an important part to play in encouraging crucial research and development (R&D). Key learning includes that

• The antibiotics market is broken. Despite global concerns about the failure of current antibiotics, industry struggles to develop the innovative drugs needed.

• The pharmaceuticals market is patent-centric and does not incentivize innovation. The development pipeline is dominated by redeveloped versions of classic compounds than to developing novel antibiotics.

• National and global incentive programmes are crucial in making the antibiotics market attractive to industry and in prompting the development of innovative, high-priority antibacterial drugs.

• Incentives must address barriers at different stages of the value chain, including the:

• – Scientific stage, for example by splitting the roles of the public and private sector in R&D

• – Regulatory stage, by speeding up approval processes and harmonizing approaches across countries, and

• – Economic stage, countering low commercial rewards compared to other therapeutic areas

• Drug regulatory agencies must strike a balance between rapid approval and ensuring that licensed drugs meet quality, safety, and efficacy standards.

• International coordination is key to reviving the antibiotics market and development pipeline.

Chapter 1.2 assesses community-based health insurance. Community-based health insurance (CBHI) is a voluntary, self-organized approach to financing health care for groups of individuals in the absence of other forms of health care coverage. CBHI scheme members organize themselves; collect and pool their insurance premiums; and use them to purchase health services for members. Key learning includes that

• CBHI is not a miracle solution to affordable access to health care.

• – The very poor often do not enroll, and when they do they tend to use fewer health services.

• – Out-of-pocket (OOP) payments are not necessarily reduced.

• Low uptake, poor delivery of promised benefits and challenges around governance undermine the impact of CBHI.

• CBHI does not overcome broader issues such as a lack of financial resources.

• CBHI might serve as a transitionary mechanism towards UHC and offer some financial protection for the most vulnerable provided that

• – Policy-makers create a supportive political and economic environment

• – Social capital can be mobilized

• – Schemes are institutionalized within the health sector.

This final chapter proposes a more reflective stance on the overall project of a regional, dialogical case study and considers the many ways by which it can be said to be dialogical. First, it recalls that research itself is always emerging as part of many collaborative dialogues around a theme, which itself can be evolving over time. Second, it highlights that a regional case study entails per definition a collective dialogue with a region and its actors, often beyond the specific project itself. Third, it summarises the deliberate use of techniques mobilised to catalyse dialogue with the region – here, participatory and art-based methods, among others. It also clarifies the type of intervention led when adopting a dialogical epistemological and ethical stance. Finally, the chapter closes with the more general implications of the present study to reflect upon dialogical approaches.

Chapter 2.1 tackles risk pooling. Risk pooling refers to the way prepaid funds are combined and then used to provide care for a covered population. Pooling is an often-underappreciated aspect of health financing which shapes the overall health system. Key learning includes that

• Pooling prepaid funds is central to progressing towards UHC. It bolsters health system efficiency and equitable access to services.

• Pooling maximizes redistributive capacity and allows the health system to align funding with needs and social priorities.

• Having multiple risk pools can be problematic, particularly if

• – pools have too few people;

• – if everyone in the pool has similar risks, and

• – if there is no redistribution of resources across pools.

• Structuring and managing risk pools well can offset problems associated with fragmentation by

• – Reducing duplication or overlap, making purchasing and service delivery more effective

• – Avoiding disproportionately large financial burdens falling on particular pools and,

• – Minimizing risk selection and ‘cream-skimming’ whereby pools try to exclude high-risk (and therefore high cost) individuals.

• Policy-makers can use a range of pooling strategies to enhance efficiency, equity and access but path dependencies and context matter. Options include

• – Encouraging the integration (i.e. consolidation or merger) or coordination of pooling schemes

• – Boosting funding for less endowed pools

• – Equalization through risk adjustment across pools via direct transfers between schemes

• – Making membership compulsory or

• – Aligning data systems, benefit packages and payment infrastructure across pools.

Chapter 2.3 reports on low-value care and how to reduce waste. Decommissioning or disinvesting from low value care means taking money away from health care services that give poor value for money. Key learning includes that

• Ending investment in health technologies or treatments that are ineffective releases resources for more effective high-value care, increases efficiency and quality and contributes to sustainability.

• Disinvesting from or decommissioning low-value care often faces institutional barriers.

• Health technology assessment (HTA) and the continuous monitoring of peer-reviewed evidence and administrative health care data are key in identifying low-value care and prioritizing what should be decommissioned.

• Combining financial and non-financial mechanisms can help influence both the supply of and demand for low-value care and stop its provision.

• Broad stakeholder consultation and engagement is a key part of ending the use of low-value care because patients, clinicians, health related organizations and health system norms and structures can all create barriers to change.

• Decision-makers need to address how resources released by disinvestment can best be re-invested to strengthen efficiency, quality and access.

Avoiding the normative language of ’successful’ or ’positive’ ageing, this book suggests that the quality of life of older persons is related to whether they can pursue their engagements, maintain the social relationships they find suitable and find a satisfying evolution of their dynamic patterns while supporting an orientation to the future. This chapter suggests that a changing landscape of care is likely to constitute a landscape of affordances for older persons, from which they can draw resources to support their development. It then reflects on the issues of moving house as part of the dynamics of ageing in place; moving may actually be part of developmental dynamics. This leads to the question of the right place to age and the timing of moving. The chapter further highlights the many shapes that living in place can take; finally, the chapter concludes with a series of recommendations.

This chapter presents past promising streams of studies aiming to describe and understand ageing. First, environmental gerontology approached ageing in relationship to the supportive or constraining role of the environment, and especially, of modalities of housing. Grounded in Lewin’s work, initiated by Powell Lawton in the 1970s, it disappeared at the turn of the millennium. In developmental psychology, a series of authors, such as Charlotte Büher, Robert Havighurst, Erik Erikson and others initiated comprehensive approaches to ageing as part of the course of life. Eventually, these were also replaced by more cognitive and normative approaches, and were mostly absorbed into lifespan psychology.

Chapter 3.6 addresses how payment mechanisms can foster value for money and quality in long term care. Payment and resource allocation mechanisms for long-term care (LTC) are distinct from those for health care for a number of reasons. Key learning includes that

• LTC is particularly prone to poor quality or inadequate care, under-provision, overmedicalization and to delivery in sub-optimal settings.

• The challenges for LTC reflect its differences from conventional health care markets, including that:

• – In health care the focus is on curing disease whereas, once an individual needs LTC, that need for care is permanent and the emphasis shifts to maintaining quality of life

• – LTC is often provided by low-paid or informal (often unpaid) caregivers rather than professionals.

• – LTC markets are generally fragmented, with a multitude of funding sources and purchasers involved.

• – Collecting data on LTC quality is difficult and makes value-based payments particularly challenging.

• Well-designed economic incentives can influence the type, setting, volume and quality of care offered, particularly when

• – Payments are adjusted to reflect cost variations between patients

• – Payment types are combined and include mechanisms to reward quality and cost containment.

• Informal caregivers may be compensated either with cash or non-monetary benefits. Although these do not normally cover the full costs of providing care, they acknowledge carers’ contributions and to some extent address issues such as working hours lost.

Chapter 2.4 gives an overview of user charges. User charges are out of pocket (OOP) payments made at the point of use for health services. Nearly all countries have some user charges, most commonly for medicines. They are intended to raise revenue and also to reduce the use of unnecessary health care services and products. Key learning includes that

• User charges can generate revenues but have many unintended negative consequences – creating barriers to access, contributing to inequities and increasing the risk of financial hardship for households.

• Health systems can reduce unnecessary or wasteful use of care without user charges by

• – Strengthening prescribing and referral systems to make sure care is appropriate

• – Offering more information to steer patients and providers towards more cost-effective care.

• Supply-side mechanisms that guide providers’ behaviour are more equitable and effective than demand-side mechanisms like user charges and have fewer negative impacts on patients – especially those with chronic or severe conditions or the economically disadvantaged.

• User charges are a suboptimal policy but – if they are to be used – health systems can mitigate the harm they cause and protect health care users through mechanisms such as exemptions, reduced copayments, income-related copayment caps, and to a lesser extent, price control and regulation.