This chapter rejuvenates the promising but lost field of environmental gerontology. Environmental gerontology threatened to disappear after the death of its initiator, Powell Lawton. The chapter reviews recent developments and problems in these approaches, and shows how the sociocultural perspective presented here may offer a satisfying way to pursue these efforts. The first section comes back to the core concepts of spaces, places and affordances. The next one proposes a dialogue with two propositions made by Lawton: first, the importance of an ideographic approach to environments of ageing, to which we have proposed a regional case study. Second, Lawton made a typology of modes of housing for older persons, calling for intermediary ones; I propose a revised typology. Finally, I integrate our findings in terms of human development together with an ecological understanding of ageing, thus sketching a more complete psychology of ageing in a changing environment.

Chapter 1.3 considers voluntary health insurance (VHI). VHI is paid for privately by or on behalf of individuals and normally covers care in addition to the publicly financed benefits package. Premiums are not typically based on the policyholder’s income but may well vary depending on their risk of ill health. Key learning includes that

• Despite prepayment and risk pooling, VHI has limitations and does not align well with progress towards universal health coverage because:

• – Risk pools in VHI schemes are typically much smaller than pools established through statutory schemes which means there are fewer people to share risk

• – Inequities are created because of the cost of premiums, which may not be affordable or accessible to everyone including those most in need.

• VHI has wider equity implications because it offers those who can afford to pay faster access or greater choice of services (supplementary insurance) or coverage of excluded services or user charges for statutory care (complementary insurance)

• Governments seeking to use VHI to expand coverage typically have to make significant interventions, including through tax subsidies to make premiums more affordable, but this creates market distortions and is inefficient.

• Policy-makers can secure better value for money by improving access to publicly financed health care than by promoting VHI.

This theoretical chapter first proposes, within an open dynamic approach, a vocabulary to address the embodied person and their experience, and the material, social and symbolic environments in which they live, which are experienced physically, relationally and interpreted via semiotic processes. Then, it highlights the implications of a regional case study for the theorising of human development, notably, thanks to its attention to the interdependency between socio and microgenetic dynamics and ontogenesis. Further, it proposes a new series of concepts and dynamics to account for development in older age, where people are likely to find new ways to develop in a world whose forces may feel progressively more adverse. Hence, the model of reconfiguration of domains of conduct needs to be completed by an understanding of envelopes that supports centripetal dynamics, borrowed from psychoanalysis. Finally, the chapter examines the implication of this proposition for the theorising development in the lifecourse.

Chapter 3.2 covers the way hospitals are paid. Methods for paying hospitals vary across countries and include fee-for-service, block contracts, line-item budgeting (where purchasers specify exactly what funds are used for), and activity-based funding (with a fixed rate for each episode of care independent of the hospital’s costs of care). Increasingly, pay-for-performance elements are also used. Key learning includes that

• Third-party purchasers: government agencies, social health insurance funds, or insurance companies provide the bulk of hospital revenue giving them levers to shape provision.

• Purchasers and hospitals have distinct objectives that are not always aligned — purchasers will pursue the best quality of care at the lowest price for their covered population while hospitals seek stable revenue streams to cover their costs.

• Information asymmetries give hospitals advantages over purchasers.

• Purchasers use payment methods and financial rewards to incentivize the volume and quality of care, patient-mix and management effort they want. There are complex challenges around

• – Specifying the details

• – Negotiating effective contracts, and

• – Managing payment systems.

• Monitoring outputs and safeguarding quality requires structures and systems which are costly.

• Reforming funding or transitioning from one payment model to another is often a long process that demands sophisticated design and careful implementation.

Chapter 3.5 reflects on how to use payment mechanisms to support the integration of care. Integrated care is about better management of the care patients receive in different settings (primary, secondary) and from different specialists and teams. It is particularly important for patients with multi-morbidity and chronic long-term needs, and as populations age. Key learning includes that

• Health systems’ payment models can play an important role in incentivizing integrated care.

• Purchasers are now testing innovative payment models (e.g. pay-for-coordination or P4C) which explore how to foster better coordination. These models include

• – Appointing a ‘budget holder’ for a patient so a case manager and /or multidisciplinary team has oversight of all care

• – Bundling payments to single providers so that the multiple services a patient uses are better linked and

• – Bundling payments for patients being treated by multiple providers, creating joint budget responsibility and a need to work together and avoid duplication.

• Policy-makers would do well to focus on careful design of information systems to underpin payment schemes because

• – Information sharing supports clinical effectiveness

• – Quality indicators allow purchasers to tie bonuses or penalties to integration

• – Monitoring activity and health outcomes helps assess value for money

• – Tracking the distributional consequences of incentive schemes is crucial in protecting equity

• – Robust evaluation tools allow immediate lessons to be shared and will capture changes over time and across the healthcare system.

• Health systems need to embed financial incentives as part of a broader system approach. Critical elements include

• – Committed leadership

• – Effective communication among providers

• – Structural integration, either through coordinating mechanisms that link provider roles or by the formation of new entities with single management teams.

Chapter 3.8 highlights the importance of funding as a tool for preparing for and responding to pandemics. A pandemic can wreak health, societal and economic havoc. Prioritizing common and global public goods for health and specifically for pandemic planning is complex and requires financing mechanisms at national, regional and supranational levels. Key learning, including from COVID-19, is that

• – Pandemic preparedness is subject to inherent market and collective action failures and is often underfunded.

• – Governments need clear strategies for funding preparedness.

• – Preparedness depends on strong health system foundations and contingency funding mechanisms that go beyond simply setting funds aside. It is crucial that funds can be mobilized quickly and in a coordinated fashion.

• – Key steps for planning responses include

• Assessing existing activities and mapping value for money

• Agreeing the need for public financing for population-based functions (i.e. common goods)

• Identifying appropriate types of financing that reflect the complexity of determining resource needs and allow for nuanced cost estimation

• Developing context-specific financing tools that include flexible funds and address accountability

• Holding transparent discussions about trade-offs

• Improving budget transfer mechanisms

• Integrating domestic finance into multiyear budgets, and

• Managing and strengthening international collaboration

• International guidance and learning from COVID-19 can help inform preparations. Organizations including the WHO and World Bank offer tools to help decision-makers. It is crucial that these are assessed for suitability to context and customized to the national and local setting.

Chapter 3.4 explores how pharmaceutical care is financed. Paying for medicines includes how the end-purchase of existing medicines is managed but also the way investment in research and development (R&D) is handled. Key learning includes that

• Pharmaceutical innovation draws on substantial public and private resources.

• – The public sector primarily supports early-stage research, regulates the industry and incentivizes development.

• – The private sector is typically central to development, commercialization, manufacture and marketing. It seeks high profit margins and is not always transparent or responsive to policy priorities.

• Novel and specialized therapeutics as well as population ageing are likely to accelerate medicines expenditures. This requires careful management of pricing and reimbursement.

• Policy-makers can leverage a mix of push and pull strategies to align industry efforts with societal need including through

• – Clear communication of health system priorities

• – Transparent incentive and pricing systems and measures to enhance R&D efficiency

• – Payment mechanisms that foster equity and sustainability

• – Cross-country collaboration including on preparedness, procurement and pricing transparency.

Chapter 3.10 evaluates innovative financing for neglected diseases. Neglected diseases (NDs) account for about a fifth of the global burden of disease and affect over a billion people. They are neglected because the pharmaceutical sector does not consider it profitable to develop treatments for them. This reflects that fact that NDs are most prevalent in low- and middle-income countries with relatively low purchasing potential. Key learning includes that

• Global pharmaceutical research and development (R&D) invests a disproportionate share of innovation, activity and resources in low burden diseases and fosters significant inequities.

• A range of push and pull incentive mechanisms have been developed to delink the cost of research from market profitability and promote innovation in areas of need.

• – Reduce the upfront costs by subsidizing R&D pre-discovery (push incentives) and

• – Offer a reward post-discovery (pull incentives)

• The evidence on the effectiveness and reach of incentive schemes is scant and more needs to be done to understand the relative cost-effectiveness of the different incentive mechanisms and the extent to which they mitigate inequalities in innovation and access to new medicines.

• A global, unified governance framework for needs assessment and resource allocation could usefully

• – Carry out systematic comparison of the relative needs associated with NDs globally

• – Assess the costs and benefits of addressing these

• – Set priorities for the coordinated global allocation of funding and targeted incentive mechanisms, and

• – Consider payment mechanisms that will translate research into market launches.