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Background The Covid-19 pandemic is an economic and a health crisis. Households reduced consumption expenditures as large-scale physical distancing measures, lower disposable incomes and fear of infection when engaging in many types of economic activity took hold. This, in turn, reduced domestic tax revenues at a time when governments were facing increased financial pressures to strengthen and sustain welfare states. Methods We developed a simulation model, the Covid-19 Taxination Simulator, to estimate potential economic gains and tax revenues attributable to vaccine rollouts. We apply the model to 12 European Union countries which had low vaccination rates at the beginning of 2022. Results The highest growth in aggregate personal consumption expenditure attributable to Covid-19 vaccines administered as of January 2022 is in Greece (10.8%), Slovenia (8.6%) and Czechia (8.6%), while the lowest is in Bulgaria (2.2%) and Slovakia (2.1%). If countries had vaccinated 85% of their adult population, the largest gains in consumption tax revenues would be expected in Romania (830 million Euros) and Poland (738 million Euros). Consumption tax revenues generated by meeting the 85% of the adult population target would, on their own, be large enough to fully cover the costs of expanding the vaccine rollout itself in Estonia, Latvia, Slovenia, Croatia, Czechia, Hungary and Greece. Conclusion Covid-19 vaccination rollouts not only save lives and relieve pressures on health systems, they also support economic growth and generate additional tax revenues. These revenues can partially offset the costs of vaccines programmes themselves.

There has been an unprecedented global effort by researchers from many disciplines to obtain and synthesize knowledge to inform policy responses to SARS-CoV-2. While many major advances have been made in generating and applying knowledge on a pandemic caused by a novel pathogen, some things could have been done better, as revealed by the devastating loss of life and economic impact on livelihoods and communities. We reflect on the context in which the pandemic emerged, characterized by underinvestment in public health and growing distrust in institutions, followed by an overview of three broad areas: generation of new knowledge, synthesis of existing knowledge, both what was known prior to the pandemic and what emerged during it, and the challenges of translating knowledge into policy. We also consider areas that were largely overlooked in the research effort. Across all areas, we aim to draw out relevant lessons for future research and public health practice.

Background Disparity in cancer survival across countries has been linked to variation in cancer policy delivery but there is lack of empirical evidence for this association. We traced the evolution of cancer policies in 20 jurisdictions in Australia, Canada, Denmark, Ireland, Norway, New Zealand and the UK since 1995 and present the findings of an exploratory analysis linking cancer policy consistency to cancer survival. Methods We systematically searched and analysed national/regional cancer plans and strategies, mapping timelines of cancer policy evolution. For 10 jurisdictions, evidence was synthesised into five categories: oversight function; cancer plan; implementation plan; budget for plan implementation; and evaluation. We assigned scores evaluating whether a category was present or absent, and weighted scores for consistency. Summed scores were correlated with trends in survival from seven cancers between 1995-2014. Results All ten jurisdictions had implemented a high-level structure overseeing, steering or delivering cancer control policies (1995 - 2014); all had also published at least one major cancer plan. There was great variation in oversight mechanisms, ranging from institutionalising cancer control (New South Wales, Ontario) to cancer steering groups or taskforces (Denmark, Northern Ireland, Wales). Frequency and consistency of cancer plans also varied, from a succession of plans that build on each other (Denmark, New South Wales, Ontario) to the publication of isolated plans (New Zealand, Northern Ireland). We found a positive, albeit weak, correlation of cancer policy consistency and improvements in survival over time for six of the seven cancers. Conclusions Jurisdictions that have implemented consistent cancer control policies over time tended to be more successful in improving survival for a wide range of cancers. Our findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes. Key messages • Sustained and consistent strategic cancer planning and investment are crucial for ensuring better patient outcomes, and this requires strong and sustained commitment at all levels. • The findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.

Background The corporate political activities of harmful industries, including the use of agnogenic (ignorance or doubt producing) practices and the construction of dystopian narratives, directed at influencing policymaking are well documented. However, the use of agnogenic practices by industry-funded organisations who deliver industry-favoured education-based measures remains unexplored. This study aims to build understanding of this by analysing three UK gambling industry-funded youth education programmes that represent key policy responses to gambling harms. Methods Using a published typology of corporate agnogenic practices the ways that evidence is used within the programmes’ resources to legitimise their content and implementation were analysed. Programme evaluations and claims about the programmes’ evidence base and effectiveness were also analysed. Results Agnogenic practices, including confounding referencing, misleading summaries and evidential landscaping, that resemble those adopted by harmful industries are used within gambling industry-funded youth education programmes and by the charities that oversee their delivery. These practices serve corporate interests, distort the limited evidence in support of youth gambling education measures, and legitimise industry favoured policies. Conclusions This novel study demonstrates that agnogenic practices are used to construct utopian narratives that claim that gambling industry-favoured youth education programmes are evidence-based and evaluation-led. These practices misrepresent the literature and evaluation findings and may undermine effective policymaking to protect children and young people from gambling harms. Key messages • Gambling industry-funded education programmes warrant greater scrutiny and conflicts of interest need to be addressed. • The methods and findings of this study are of relevance to other contexts and areas in the field of the commercial determinants of health given other harmful industries adopt similar approaches.

Background Greece experienced the largest reduction in its health care budget of any European country during the economic crisis of 2008–15. Here, we test the hypothesis that budget reductions worsened health system performance in Greece, using the concept of Amenable Mortality to capture deaths which should not occur in the presence of effective and timely health care. Methods Amenable mortality was calculated from national mortality statistics, using age-standardized deaths from 34 conditions amenable to medical intervention in Greece during 2000–16, with further analysis by sex, age, region and cause. Mortality rate ratios and their 95% CI were also computed. Interrupted time series analyses were performed to compare trends prior to austerity measures (2001–10) with those after (2011–16), adjusting for historical trends. Results Prior to austerity measures, amenable mortality rates were declining. After 2011, coinciding with the inception of budget reductions, the slope of decline diminished significantly. The average annual percent of change in standardized death rates was 2.65% in 2001–10, falling to 1.60% in 2011–6. In 10 of 34 conditions, the SDR increased significantly after the crisis onset, and in five more conditions the long-term decline reversed, to increasing after 2011. The age-specific mortality rates observed in 2011–16 were significantly higher than those expected at ages 0–4 and 65–74 but not significantly higher in all other age groups. Conclusions Health system performance in Greece worsened in association with austerity measures, leading to a deceleration of the decline in amenable mortality and increased mortality from several conditions amenable to medical interventions.

In 2015, the world’s governments committed, in the Sustainable Development Goals (SDGs), to achieve universal health coverage by 2030, something they will be held accountable for. We examine progress in the WHO European Region using data from several sources. We assess effective coverage using data from the Global Burden of Disease Programme, including access to 9 key interventions for maternal and child health and communicable and non-communicable diseases and mortality from 32 conditions amenable to health care. Progress is mixed; while Finland and Iceland have already achieved the 2030 target already, other countries, including in the Caucasus and Central Asia have not yet, and are unlikely to by 2030. We then examine financial protection, where progress lags in Central and South East Europe and the former Soviet Union, where high out-of-pocket healthcare payments and catastrophic spending are still common. We stress the need to consider inequalities within countries, with the most vulnerable groups, such as Roma or newly arrived migrants (from the Middle East and Africa) often underserved, while their needs are frequently undocumented. To make progress on the SDGs, governments must invest more heavily in health services research and support the infrastructure and capacity required to enable it.

Background There are widespread concerns that workers in precarious employment have suffered the most in the COVID-19 pandemic and merit special attention. The aim of this rapid scoping umbrella review was to examine what evidence exists about how COVID-19 has affected the health of this highly vulnerable group, and what gaps remain to be investigated. Methods Five databases were searched for systematic or scoping reviews from January 2020 to May 2021. The quality of the included reviews was determined using A MeaSurement Tool to Assess systematic Reviews. Results We identified 6 reviews that reported 30 unique relevant primary studies. The included studies indicate that essential (non-health) workers are at greater risk of COVID-19 infection and case fatality than others in their surrounding community. The occupational risk of exposure to COVID-19 also seems to be greater among more precarious categories of workers, including younger workers and workers in low-income and low-skilled occupations. Further, hazardous working conditions faced by many essential workers appear to have amplified the pandemic, as several occupational sites became ‘super-spreaders’, due to an inability to socially distance at work and high contact rates among workers. Finally, employment and financial insecurity generated by the pandemic appears to be associated with negative mental health outcomes. The quality of the included reviews however, and their primary studies, were generally weak and many gaps remain in the evidence base. Conclusions Our study highlights that COVID-19 is creating new health risks for precarious workers as well as exacerbating the pre-existing health risks of precarious employment.

Introduction Manufacturers, such as producers of cigarettes, drugs or ultra-processed foods, influence health policy, research and practice. This influence is one of the main barriers against the implementation of public health policies around the world. Our goal was to identify existing mechanisms to limit this influence. Methods We conducted a scoping review in 2019. We searched five scientific databases: Web of Science Core Collection; BIOSIS; MEDLINE; Base; Scopus. Twenty-eight institutions and networks related to our research objective were also contacted to identify additional mechanisms and examples. In addition, we identified mechanisms and examples drawn from our collective experience. We have classified the mechanisms into two groups: those of international organizations and governments; those for universities, the media and civil society. Results Thirty-one publications were included in our review, including eight scientific articles. Nine mechanisms focused on several industries; while the other documents targeted specific industries. We identified 49 mechanisms that could help limit corporate influence in health policy, science and practice. For 41 of these mechanisms, we found examples, around the world, where they have been implemented. The main objectives of the mechanisms identified were to manage conflicts of interest and ethical issues, while increasing the transparency of public-private interactions. Mechanisms for governments (n = 17) and universities (n = 13) were most frequently identified, with fewer examples existing to protect the media and civil society. Discussion The development, implementation and monitoring of these mechanisms are essential to protect public health from industrial influence. Key messages We found 49 mechanisms that could help limit corporate influence in health policy, science and practice. There are fewer mechanisms to protect the media and civil society, than to protect governments and universities.

Background Job loss is a well-established social determinant of health. Recent research has taken an ‘institutional turn’, asking whether unemployment support could buffer the health consequences of job loss. Here, we exploit a quasi-natural experiment based on the Fornero reforms in Italy, which increased wage replacement rates from 60% to 75% on 1 January 2013. Methods We employed difference-in-difference models using longitudinal data covering 202 incidents of job loss from the EU-Survey on Income and Living Conditions to quantify the impact of job loss on changes in self-reported health prior to and after the Fornero reforms (2011–14). Results Job loss pre-Fornero was associated with health declines −0.342 [95% confidence interval (CI): −0.588 to −0.096] but did not significantly influence health post-Fornero 0.031 (95% CI: −0.101 to 0.164). The difference-in-difference estimate was 0.373 (95% CI: 0.107–0.639), or a −0.51 standard deviation in self-reported health, consistent with the buffering hypothesis. To put the magnitude of this estimate in perspective, the incidence of a chronic illness, such as diabetes, results in a similar magnitude decline in self-reported health. Conclusions Our analysis contributes to a growing body of evidence that the impact of job loss on health depends critically on the strength of social protection systems and, in some cases, could be eliminated completely.

Millions of people across the world depend on health systems that simply do not work. They struggle to find someone who can help and, when they do, can face catastrophic bills for often substandard care. But we fail to listen to those whose needs, desires, and expectations are most unmet. We assume their understanding of health and illness is the same as ours and we ignore the coping strategies developed over years that they use to overcome the barriers that those who design health systems place in their way. They live their lives unseen and unheard by those who make the decisions that will determine whether they live or die. This workshop explores issues that arise when researchers actively engage with disadvantaged populations. It reports our experiences from the RESPOND project (Responsive and Equitable Health Systems - Partnership for Non-Communicable Diseases), working with disadvantaged communities in Malaysia and the Philippines to view the health system from the perspective of people whose health depends on a long-term relationship with it. We use a mixed methods approach, involving household surveys, in-depth interviews and digital diaries, where participants use mobile phones to record their experiences of living with chronic conditions and seeking care for it. The aim of this workshop is to demonstrate why it is important to listen to those in disadvantaged populations, in order to understand the barriers they face and the ways that they seek to overcome them as they seek care for a chronic disorder. We will illustrate this by achieving five objectives: To show why we need to look beyond the biomedical approach to illness;To recognise the many different journeys that patients follow;To understand the economic consequences of the choices that they make;To describe the theoretical and technical innovations developed as part of the RESPOND project to do this; andTo illustrate how bringing such insights together can be used to implement equitable health system change. The workshop will be chaired and moderated by Dina Balabanova and Martin McKee, two globally recognised leaders researching chronic conditions and health system reforms in low- and middle-income countries. The first three presentations will introduce people living with chronic conditions from the study communities, and will examine the challenges they face, their options and the choices they make to treat it. All five presentations, but particularly the remaining two, will describe the theoretical and technical innovations developed as part of the RESPOND project used to capture the voices and lived experiences of disadvantaged populations so that they may be better represented in the planning of health systems and services. The remaining 30 minutes will be devoted to guided interactive discussion with the audience on how we are using this people-centred evidence to implement change in each country, and how these approaches may be applied in other settings. Key messages Designing effective and responsive health systems that leave no one behind must account for the lived experiences of all beneficiaries, including those groups whose voices often go unheard. We present evidence from Malaysia and the Philippines from studies that used innovative methods to capture the lived experiences of disadvantaged populations seeking care for chronic conditions.

Background There is well-established variation in cancer survival across high-income countries with seemingly-similar health systems. There is much research on reasons for these differences, but the role of leadership has been under-researched despite being one of the WHO 'building blocks' that underpin a functioning health system. Leadership is variously defined as including governance, stewardship, responsibility and accountability. As part of the International Cancer Benchmarking Partnership, this study looked at these diverse aspects of leadership to identify drivers of change and improvement across a range of high-income countries. Methods Cancer strategy documents were analysed from 22 jurisdictions: Australia (3 states), Canada (10 provinces), Denmark, Ireland, New Zealand, Norway, and UK (4 countries). Key informants in 15 of these jurisdictions, representing a range of stakeholders, were recruited through a combination of purposive and 'snowball' strategies, and invited to participate in semi-structured interviews. Documents and interview transcripts were analysed using a thematic approach. Results Different facets of leadership emerged: diffused vs centralised (including the central role of a cancer agency in some places); national, regional and local leadership structures; links between primary and secondary care. This study, however, demonstrated a central role for sustained leadership and political commitment, crucial for initiating and maintaining progress, as was a coherent vision that supported the implementation of national policies locally. Clinical leadership emerged as vital for translating policy into action. Conclusions Improving cancer outcomes is challenging and complex but is unlikely to be achieved without effective leadership and sustained political commitment that can create effective co-ordination of care. Key messages Different facets of leadership of the cancer care system emerged as important when exploring the reasons for variations in cancer outcomes in high-income countries. The persistence of these variations is unacceptable. Change will require political commitment and effective leadership, especially by clinicians.

Building on the findings of presentations 1 and 2, we turn to two further measures of population health: life expectancy at birth and lifespan variation. Life expectancy at birth provides a single figure that captures the overall mortality experience of a nation, and, in the absence of data artefact, a wide-scale environmental event such as war or natural disaster, a disease epidemic or mass migration, life expectancy can be expected to continue to improve in HICs. Concurrently lifespan variation, which measures the average gap between the age at death of an individual and the remaining life expectancy at that age, should decrease as life expectancy increases. Recent analysis of life expectancy improvements in HICs by the Office for National Statistics, using Human Mortality Database data, found that while Japan continues to see improvements, the UK and the USA fell to the bottom of the rankings. Economically, both the UK and Japan have experienced 'lost decades' of poor economic growth, in 1990s and 2010s respectively. Yet, while Japan continued to see life expectancy improvements, in the UK life expectancy stalled, and both countries saw an increase in lifespan variation. In this presentation, we will present the analysis of lifespan variation of 5 HICs: the USA, where life expectancy has declined, the UK, where gains in life expectancy have trailed behind those in other industrialised countries, Japan, which has seen sustained progress, and France and Canada, neighbours of the UK and USA respectively, which lie in the middle. We will examine what can be determined from these measures over periods of poor economic growth, and the implications for achieving 'sustainable growth'.

Background The rate of improvement in life expectancy in high income countries has slowed down over the past few years, and instances where life expectancy is lower than a year before are increasingly common. This paper aims to analyse changes in life expectancy over the last decade to better understand what causes and age groups contribute to the slowdown. Methods We use WHO mortality data by age and cause to construct life tables, and we use Arriaga decomposition method to analyse the contribution of specific causes and age groups to changes in life expectancy in Australia, Canada, France, Germany, Netherlands, United Kingdom and the United States of America. We look at the change between 2007-2012 and 2012-2017 (or latest available). Results All countries experienced a slowdown in life expectancy in the past 5 years (2012-2017), in comparison to the preceding period. Slowdown in under 65s was particularly pronounced, with younger age groups only contributing minimally (between 0.4 years for males in Germany and -0.4 years for males in the United States) to changes in life expectancy. Among people aged 65 and over, gains ranged between 0.05 years for females in France and 0.6 years for males in the Netherlands. Certain causes of death contributed negatively to change in life expectancy between 2012 and 2017, with notable increases in deaths from accidental poisonings in males (up to -0.09 year in the UK and Canada, and -0.34 in the US) and suicides (up to -0.08 year in Australia and -0.07 in the US). Conclusions While recent slowdown in life expectancy gains in high income countries is often attributed to lack of improvement in people of older ages, we show that, beyond this, there are increases in mortality in younger age groups from external causes, that contribute negatively to change in life expectancy in some countries. This pattern is of a particular concern, as deterioration in preventable mortality points to broader worsening of socio-economic climate. Key messages Improvements in life expectancy in high income countries slowed down markedly over the past few years, but contributing mortality patterns differ for age groups and causes of death across countries. Persistent increases in preventable mortality from certain external causes in younger age groups in Australia, Canada, US and UK point to broader deterioration of socio-economic climate.

Being able to identify corruption and call corrupt officials, health workers and citizens to account is critical in ensuring that public health policy and practice is shaped by evidence and reason rather than by powerful political forces. Despite substantial financial investments by bilateral and multilateral agencies to combat corruption, twenty years of initiatives based on good governance, improving law and changing regulatory approaches have been hugely disappointing - failing to effect significant changes in low- and middle-income countries. Public health activism on corruption is stepping up, diverse groups of actors are organizing around the threat that corruption creates to UHC, equity, social justice and the drive for global solidarity. They cannot rely on traditional good governance accountability and transparency approaches that pay insufficient attention to combinations of poor policy, under-funding and powerful interests that shape health systems, create perverse incentives, the need for survival corruption. To be effective, we need evidence of feasible and effective anti-corruption strategies. In this workshop, building on two years of theory development, qualitative and quantitative data collection and analysis in health services in LMICS we will set how feasible and effective anti-corruption strategies can be crafted and implemented. The session will introduce the Anti-Corruption Evidence ('ACE approach') and the idea of “developmental governance”. These have been used in other sectors but this is the first time that they have been applied to health. The approach is innovative in its targeted approach and focus on welfare-enhancing policies, seeking out space where for action that simultaneously tackles corruption and improves health systems but which is also politically and institutionally feasible to introduce. These strategies mark a shift away from blue-prints, interventions applied across countries without attending to context. We will use this workshop to show participants how to attend to the ways in which power and politics, culture and social networks shape health seeking and health care provision and how targeted, politically sensitive strategies offer the best anti-corruption solutions. Key messages New approaches to anti-corruption are critical for public health. Context-sensitive politically feasible, welfare-enhancing interventions offer the best way forward for anti-corruption.

Background The Italian 180/1978 reform abolishing asylums is one of the most contested mental health programs ever implemented. It aimed to shift care of mental illness into the community improving outcomes and reducing expenditure. It was a model for successive deinstitutionalization initiatives across Europe and North America. However, there were longstanding concerns that, without expansion of community care, it may have deprived patients with mental illness access to support, placing them at increased risk of suicide. Methods Regression discontinuity models were used to quantify the association between the number of suicides and the introduction of the Basaglia Law, disaggregated by age-group and gender, covering 20 Italian regions during the period 1975–84. Models were adjusted for potential socio-demographic confounding factors, region-specific fixed effects and pre-existing time-trends. Results Italian regions implemented the Basaglia Law to varying degrees over time. We observed that, after adjusting for pre-existing time trends, the implementation was associated with a consistent increase in the number of suicides for all the age-groups [incidence rate ratio, age 15–44: 1.29, 95% confidence interval (CI) 1.18–1.41; age 45–74: 1.45, 95% CI 1.37–1.54] and for both genders (males: 1.47, 95% CI 1.41–1.53; females: 1.36, 95% CI 1.25–1.47). Hospital closure appeared to be an important mediating mechanism. Conclusions The Basaglia Law was associated with a significant increase in the number of suicides, with evidence of an association with closures of facilities, leaving those with mental illness with nowhere to go, as the envisioned community care structures failed to be developed as originally planned.

Substance use disorders are among the priority conditions identified by the World Health Organization mental health gap action program. The health community has taken a range of (non-exclusive) positions on how to respond to them. These include a spectrum from prohibition, through regulation, to harm reduction and another from individually targeted measures to collective policies. Which measures are adopted depend on many factors outside the health system, including beliefs about the relationship between the individual and the state, the power of producer interests (tobacco/ alcohol industries), and the predominant public narrative. In contrast, a public health approach would focus on the risks of harm, to the individual and society, its distribution within the population, and the potential for unintended consequences. In this workshop, we will explore policy responses to four harmful substances, in four different European countries. These are electronic cigarettes (Martin McKee), cannabis (Jean-Pierre Couteron) illegal drugs (Henrique Barros) and alcohol (Jutta Lindert). First, the case of electronic cigarettes have divided the health community. While some groups, mainly in England, have embraced them, others have expressed concerns, with US authorities describing their increasing use by adolescents as a public health emergency. We will ask why these different views exist, exploring the use of different paradigms, the prioritization of different population groups and conditions, and the role of cognitive biases. This presentation will highlight some of the wider divisions in approaches to substance use disorders. Second, the use of cannabis in France will be presented. France ranks fourth in the European Union in terms of monthly consumption of cannabis and second only to Denmark in terms of persons who have ever used cannabis. As of November 2018 the penalty for possession of cannabis in France was reduced to a €200 fine. This presentation will discuss the rationale for and expectations of this policy. Third, we will focus on Portugal which, in 2001, became the first country to decriminalise the possession and consumption of all illicit substances. Rather than being arrested, those caught with a personal supply are given a small fine or told to appear before a local commission. Finally, the challenges for Public health of harmful alcohol use will be presented. The harmful use of alcohol creates a serious health burden in refugees. Germany has among the highest alcohol consumptions in Europe, after Luxembourg, is the European country with the lowest percentage of people who abstain from drinking. Alcohol is widely accepted. This creates challenges for refugees coming from countries with much more restrictive approaches to alcohol. This presentation will explore the challenges that arise when a population coming from a regulated environment move to one that is highly liberalised, including a discussion of the challenges in developing culturally appropriate public health responses. Key messages Substance use is a major public health challenges. Legal and policy responses differ widely in the European Union - evidence based policies are highly beeded.