Measuring Active Purchasing in Healthcare: Analysing Reallocations of Funds Between Providers to Evaluate Purchasing Systems Performance in the Netherlands

BACKGROUND

Purchasing systems aim to improve resource allocation in healthcare markets. The Netherlands is characterized by four different purchasing systems: managed competition in the hospital market, a non-competitive single payer system for long-term care (LTC), municipal procurement for home care and social services, and self-procurement via personal budgets. We hypothesize that managed competition and competitive payer reforms boost reallocations of provider market share by means of active purchasing, ie, redistributing funds from high-quality providers to low-quality providers.

METHODS

We define a Market Activity Index (MAI) as the sum of funds reallocated between providers annually. Provider expenditures are extracted from provider financial statements between 2006 and 2019. We compare MAI in six healthcare sectors under four different purchasing systems, adjusting for reforms, and market entry/exit. Next, we perform in-depth analyses on the hospital market. Using multivariate linear regressions, we relate reallocations to selective contracting, provider quality, and market characteristics.

RESULTS

No difference was found between reallocations in the hospital care market under managed competition and the non-competitive single payer LTC (MAI between 2% and 3%), while MAI was markedly higher under procurement by municipalities and personal budget holders (between 5% and 15%). While competitive reforms temporarily increased MAI, no structural effects were found. Relatively low hospital MAI could not be explained by market characteristics. Furthermore, the extent of selective contracting or hospital quality differences had no significant effects on reallocations of funds.

CONCLUSION

Dutch managed competition and competitive purchaser reforms had no discernible effect on reallocations of funds between providers. This casts doubt on the mechanisms advocated by managed competition and active purchasing to improve allocative efficiency.

Effect of a relative pricing intervention and active merchandising on snack purchases: interrupted time series analysis of a hospital retailer-led strategy

BACKGROUND

Pricing policies have been shown to be an effective lever for promoting healthier dietary choices in consumer food environments. It is not yet well understood how pricing can be used to encourage healthier substitute purchases. The aim of the study was to assess the effect of a retailer-led relative pricing intervention on weekly purchases of targeted snack foods and beverages.

METHODS

This was an ecological analysis in a real-world large tertiary hospital consumer food environment setting in urban Canada, comprised of four retail outlets: two large cafeterias, one smaller cafeteria, and one grab-and-go café. An interrupted time series analysis was designed to evaluate the effect of Snacking Made Simple, a retailer-led relative pricing intervention applied to 10 popular snack foods and beverages (n = 87 weeks, 66 weeks baseline and 21 weeks intervention, April 2018 to December 2019), on weekly purchase differences between healthier and less healthy targeted items, adjusted for weekly sales volume. Five healthier items were price discounted, alongside a price increase for five less healthy items. The intervention was actively merchandised in keeping with behaviour change theory.

RESULTS

Weekly purchases of targeted snacks became healthier during the intervention period (β = 21.41, p = 0.0024). This followed a baseline period during which weekly purchases of less healthy targeted snacks had outpaced over time those of healthier targeted snacks (β = -11.02, p = 3.68E-14). We estimated that, all else being equal, a hypothetical 9.43 additional weeks of the intervention would be required to transition to net-healthier targeted snack purchases in this environment. The effects of the intervention varied by retail outlet, and the outcome appears driven by specific food items; further, examining merchandising implementation, we posited whether direct versus indirect substitution may have affected purchasing outcomes.

CONCLUSIONS

Relative pricing may be a promising way to incentivize healthier substitute purchasing in the consumer food environment. Added attention to merchandising strategy as well as value-add factors within food categories and their effects on price salience may be an important factor in effective intervention design.

Citizen engagement in healthcare procurement decision-making by healthcare insurers: recent experiences in the Netherlands

BACKGROUND

In insurance-based healthcare systems, healthcare insurers are interested in engaging citizens in care procurement to contract healthcare services that matter to people. In the Netherlands, an amendment to the Health Insurance Act was set forth in 2021 to formalize and strengthen the engagement of the insured population with healthcare insurers' procurement cycles. This study explores the role of Dutch healthcare insurers in operationalizing citizen engagement in procurement cycles before changes occur linked to the amendment to the Health Insurance Act.

METHODS

A phenomenological qualitative design was employed in two phases: (1) we consulted academics and policy experts on the role of healthcare insurers regarding citizen engagement; (2) we conducted focus groups with representatives of healthcare insurers to understand how citizens' engagement is being operationalized. Transcripts of the interviews with experts and detailed notes of focus group meetings were analysed using a qualitative inductive approach. Selected excerpts were analysed on discourse and content and organized by a coding scheme following a rigorous and accelerated data reduction technique.

RESULTS

We identified four strategies used by healthcare insurers to operationalize citizen engagement: (1) broadening their population health orientation; (2) developing and improving mechanisms for engaging citizens; (3) strengthening features of data governance for effective use of value-driven data; (4) implementing financial and incentive mechanisms among healthcare providers in support of value-based healthcare. However, regulated market mechanisms and low institutional trust in healthcare insurers undermine their transition from merely funding healthcare towards becoming people-centred value-based healthcare purchasers.

CONCLUSION

Dutch healthcare insurers seem to be strengthening the community orientation of their functioning while enhancing the end-to-end experience of the insured. The expected practical effects of the amendment to the Health Insurance Act include broadening the role of the council of insurees in decision-making processes and systematically documenting the efforts set forth by healthcare insurers in engaging citizens. Further research is needed to better understand how the regulated competitive market could be hampering the engagement of citizens in healthcare procurement decision-making and value creation from the citizens' perspective.

Factors Influencing Procurement of Digital Healthcare: A Case Study in Dutch District Nursing

BACKGROUND

Digital health is considered a promising solution in keeping health care accessible and affordable. However, implementation is often complex and sustainable funding schemes are lacking. Despite supporting policy, scaling up innovative forms of health care progresses much slower than intended in Dutch national framework agreements. The aim of this study is to identify factors that influence the procurement of digital health particular in district nursing.

METHODS

A case study approach was used, in which multiple stakeholder perspectives are compared using thematic framework analysis. The case studied was the procurement of digital health in Dutch district nursing. Literature on implementation of digital health, public procurement and payment models was used to build the analytic framework. We analysed fourteen interviews (secondary data), two focus groups organised by the national task force procurement and eight governmental and third-party reports.

RESULTS

Five themes emerged from the analysis: 1) rationale 2) provider-payer relationship, 3) resources, 4) evidence, and 5) the payment model. Per theme a number of factors were identified, mostly related to the design and functioning of the Dutch health system and to the implementation process at providers' side.

CONCLUSION

This study identified factors influencing the procurement of digital health in Dutch district nursing. The findings, however, are not unique for digital health, district nursing or the Dutch health system. The results presented will support policy makers, and decision makers to improve procurement of digital health. Investing in better relationships between payer and care provider organisations and professionals is an important next step towards scaling digital health.

Was COVID-19 associated with increased cigarette purchasing, consumption, and smoking at home among US smokers in early 2020? Findings from the US arm of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey

Evidence of the impact of COVID-19 and mandatory stay-at-home orders on cigarette smoking is mixed. In the United States, household tobacco purchases increased in early 2020, but it is unclear whether this was associated with increased smoking. Using individual-level, longitudinal data from a representative cohort of US smokers (n = 3046), this study tested whether (1) carton purchases of cigarettes increased in early 2020 relative to the same calendar period in 2018, (2) more smokers permitted smoking inside their homes, and (3) smokers increased the number of cigarettes they smoked per day. Weighted multivariable logistic regression tested whether trends in carton purchasing and smoke-free homes differed in 2020 compared to 2018 while weighted multivariable linear regression tested whether trends in cigarette consumption differed in 2020 compared to 2018. Overall, 24.0% of US smokers last purchased cigarettes by the carton in early 2018; this increased to 28.8% in early 2020 (p = 0.007). Average daily cigarette consumption and the percentage of smokers reporting that smoking was not allowed inside their homes did not differ between 2018 and 2020 (p = 0.92 and p = 0.054, respectively). Overall, these findings suggest that COVID-19 mitigation measures implemented in the spring of 2020 had limited impact on the smoking behavior of US adult smokers.

How much do government and households spend on an episode of hospitalisation in India? A comparison for public and private hospitals in Chhattisgarh state

BACKGROUND

Improvements in the financing of healthcare services are important for developing countries like India to make progress towards universal health coverage. Inpatient-care contributes to a big share of total health expenditure in India. India has a mixed health-system with a sizeable presence of private hospitals. Existing studies show that out-of-pocket expenditure (OOPE) incurred per hospitalisation in private hospitals was greater than public facilities. But, such comparisons have not taken into account the healthcare spending by government.

METHODS

For a valid comparison between public and for-profit private providers, this study in Indian state of Chhattisgarh assessed the combined spending by government and households per episode of hospitalisation. The supply-side and demand-side spending from public and private sources was taken into account. The study used two datasets: a) household survey for data on hospital utilisation, OOPE, cash incentives received by patients and claims raised under publicly funded health insurance (PFHI) schemes (n = 903 hospitalisation episodes) b) survey of public facilities to find supply-side government spending per hospitalisation (n = 64 facilities).

RESULTS

Taking into account all relevant demand and supply side expenditures, the average total spending per day of hospitalisation was INR 2833 for public hospitals and INR 6788 for private hospitals. Adjusted model for logarithmic transformation of OOPE while controlling for variables including case-mix showed that a hospitalisation in private hospitals was significantly more expensive than public hospitals (coefficient = 2.9, p < 0.001). Hospitalisations in private hospitals were more likely to result in a PFHI claim (adjusted-odds-ratio = 1.45, p = 0.02) and involve a greater amount than public hospitals (coefficient = 0.27, p < 0.001). Propensity-score matching models confirmed the above results. Overall, supply-side public spending contributed to 16% of total spending, demand-side spending through PFHI to 16%, cash incentives to 1% and OOPE to 67%. OOPE constituted 31% of total spending per episode in public and 86% in private hospitals.

CONCLUSIONS

Government and households put together spent substantially more per hospitalisation in private hospitals than public hospitals in Chhattisgarh. This has important implications for the allocative efficiency and the desired public-private provider-mix. Using public resources for purchasing inpatient care services from private providers may not be a suitable strategy for such contexts.

Household expenditure on non-Covid hospitalisation care during the Covid-19 pandemic and the role of financial protection policies in India

BACKGROUND

Despite global guidance for maintaining essential non-Covid health services during the pandemic, there is a concern that existing services faced a major disruption. The access as well as affordability of healthcare could have suffered during the pandemic, especially in developing countries including India. There are no population based studies available in India on changes in access and financial risk for non-Covid hospitalisation during the pandemic. India has a policy of Publicly Funded Health Insurance (PFHI) to ensure access and financial protection for hospital care but no information is available on its performance during the pandemic. The current study was aimed to find out the change in access and financial protection for non-Covid hospitalisations during the Covid-19 pandemic and to examine the performance of PFHI in this context.

METHODS

Panel data was analyzed, from two rounds of annual household surveys conducted in Chhattisgarh state for year 2019 and 2020. The survey followed a two-stage population based sample of around 3000 households, representative for the state. Two kinds of measures of catastrophic health expenditure were used - based on annual household consumption expenditure and on non-food consumption expenditure. Multivariate analysis was carried out to find determinants of utilisation and spending. In addition, Propensity Score Matching method was applied to find effect of PFHI schemes.

RESULTS

Utilisation of hospital care per 1000 population reduced from 58.2 in 2019 to 36.6 during the pandemic i.e. in 2020. The share of public hospitals in utilisation increased from 60.1% in 2019 to 67.0% in 2020. Incidence of catastrophic expenditure was significantly greater during the pandemic. The median Out of Pocket Expenditure (OOPE) in private hospitals doubled from 2019 to 2020. The size of OOPE and occurrence of catastrophic expenditure were significantly associated with utilisation in private hospitals. Enrolment under PFHI schemes including the Ayushman Bharat-Pradhan Mantri Jan Arogaya Yojana (PMJAY) was not effective in reducing OOPE or catastrophic expenditure.

CONCLUSION

While the utilisation of hospital care dropped during the pandemic, the private hospitals became further unaffordable. The government policy for financial protection through health insurance remained ineffective during the pandemic.

Impact of increasing the relative availability of meat-free options on food selection: two natural field experiments and an online randomised trial

BACKGROUND

Increasing the availability of lower energy-density foods is a promising intervention to encourage healthier food purchasing but few studies have examined the effect of increasing availability of meat-free meals to promote more sustainable purchasing. We report three studies, all examining the impact of altering the availability of meat-free meals on meal selection.

METHODS

Study 1 (a natural experiment in one university cafeteria) examined the impact of altering the ratio of meat-free meals (one meat-free and two meat, to two meat-free and one meat) on weekly sales of meals containing meat. Study 2 (a natural experiment in 18 worksite cafeterias) examined the impact on meat-free meal sales of a menu change designed to increase the availability of meat-free meals. Study 3 (an online study of 2205 UK-representative adults) compared meal selections when participants were randomised to ranges comprised of (a) one meat-free, three meat options; (b) two meat-free, two meat; or (c) three meat-free, one meat.

RESULTS

Study 1 suggested a significant decrease in the proportion of sales of meat options when the availability of meat-free options increased (- 19.9 percentage points; 95%CIs:-25.2,-14.6), with no evidence of changes to meat-based meal sales in other university cafeterias during the same period. Findings from Study 2 were mixed: multilevel regressions found no evidence of an increase in meat-free meals following the menu change (2.3 percentage points; 95%CIs: - 1.3,5.9), while interrupted time-series analyses suggested sales did increase (2.3; 95%CIs: 0.4,4.2), but implementation of the planned change was limited. In Study 3 reducing meat-free options from 50 to 25% reduced participants' selection of meat-free options (odds ratio 0.35; 95%CIs: 0.26,0.46), while increasing meat-free options from 50 to 75% increased meat-free selections (odds ratio 2.43; 95%CIs: 1.94,3.04). There was no evidence effects were moderated by gender, socioeconomic status or usual meat consumption.

CONCLUSION

Increasing the availability of meat-free options is effective at reducing meat selection and purchasing for different ratios of meat to meat-free options. The magnitude of the effect is uncertain, but with no evidence of differences in response by demographic groups when directly tested.

TRIAL REGISTRATION

Study 3: Open Science Framework; https://osf.io/ze9c6 ; 6/8/2020.

The impact of COVID-19 on consumers' eating and purchasing habits of agricultural products in China: key determinants and policy implications

BACKGROUND

The study looks at a changed in consumer's eating and purchasing habits during COVID-19 period. There are several modes of transmission but transmission through food as being speculated is one area that has not been confirmed through research. The study, therefore, looks at how speculations about COVID-19 spreading through food has affected consumers' eating and purchasing habits. This study through probit model analysed how consumers' eating and purchasing habits have been influenced.

RESULTS

The result shows that age, gender and education have negatively influenced consumer's eating and purchasing habits during the COVID-19 pandemic compared to pre-pandemic period. The preference for imported food items, preference for frozen food, been infected or knowing someone who has been infected by the virus, and been infected through agricultural source or knowing someone who has been infected by the COVID-19 through agricultural source have negatively affected consumers' eating and purchasing habits compared to pre-pandemic period. The result, however, suggests that consumers who trust in the cold-chain food systems ability to limit the spread of the COVID-19 still maintain a positive eating and purchasing habits.

CONCLUSIONS

The study provides evidence on the impact of COVID-19 on consumer's eating and purchasing habits. Therefore, there is the need to institute proper sanitary measures, especially at cold-chain food systems to help curb the spread and also boost consumers' confidence.

Retail availability and legal purchases of dried flower in Canada post-legalization

OBJECTIVE

Retail availability of cannabis has the potential to influence demand for both legal and illegal cannabis. The aims of the study were to: 1) estimate the percentage of consumers who report purchasing dried flower legally; and 2) examine the association between purchasing dried flower legally and retail availability, where retail availability was represented as: a) Canadian province; b) 'objective' retail proximity; and c) self-reported retail proximity.

METHODS

Data come from Canadian respondents in Wave 2 of the International Cannabis Policy Study (ICPS) conducted one year after non-medical cannabis legalization in September-October 2019. Respondents were 18+ years in Alberta/Quebec and 19+ years elsewhere and had purchased any dried flower in the past year (n = 2506). Respondents were recruited through commercial online panels. Weighted binary logistic regression models examined likelihood of purchasing dried flower legally.

RESULTS

Overall, 47.7 % of past-year dried flower purchasers reported last purchasing dried flower legally, with variation across provinces (range = 40.5 %-81.2 %). Likelihood of purchasing dried flower legally was greater among those who lived closer to a legal retail store based on Euclidean distance (<3 km vs. > 10 km: AOR = 1.56, 95 % CI: 1.20,2.02), and who had shorter self-reported travel time to a retail store (<5 min. vs. > 15 min.: AOR = 2.24, 95 % CI: 1.56,3.21).

CONCLUSION

One year after legalization, retail availability was associated with last purchasing dried flower legally among past-year dried flower purchasers. To our knowledge, the current study is among the first to examine the legality of purchase source used for dried flower and retail availability of cannabis in Canada post-legalization.

[French national overview of the inclusion of environmental criteria in the public purchasing of health products (drugs and sterile medical devices)]

OBJECTIVES

Healthcare products (HP) have a significant carbon footprint that must be included by regulation in the facility's purchasing policy. A national overview of the inclusion of environmental criteria (EC) in the public procurement (PP) of HP in hospitals has been carried out.

METHODS

Thirty EC were identified in the literature. Two questionnaires were proposed: (i) for buyers that analyze the level of "importance" and "ease of application" for public tenders (PT), and (ii) for suppliers that declare their commitments and evidence.

RESULTS

Six regional buyers and 28 suppliers participated. Buyers recognize the "importance" of sustainable development (SD) but are more reticent about the "applicability" of EC in PT. The environmental rating remains low: on average 4.38 (0.25-10.00) % of the total rating. Only 12 EC are integrated within some PT. Suppliers report a high and diversified commitment to SD: 18 suppliers sent 474 evidence. Buyers and suppliers converge on the optimization of primary packaging and the establishment of a minimum order or delivery group.

CONCLUSIONS

Since the efficiency of PP is inevitable, EC that combines SD and savings should be prioritized. The integration of additional EC, simple and easily documented, allowing cost containment for both suppliers and buyers, is possible to promote sustainable purchasing.

Case studies for implementing MCDA for tender and purchasing decisions in hospitals in Indonesia and Thailand

Background

A multi-criteria decision analysis (MCDA) approach has been suggested for helping purchasers in low- and middle-income countries in an evidence-based assessment of multi-source pharmaceuticals to mitigate potential adverse consequences of price-based decisions on patient access to effective medicines. Six workshops for developing MCDA-instruments for purchasing were conducted in Indonesia, Kazakhstan, Thailand, and Kuwait in 2017–2020. In Indonesia and Thailand, two pilot-initiatives aimed to implement the instruments for hospital drug purchasing decisions.

Objective

By analysing and comparing the experiences and progress from the MCDA-workshops and the two case-examples for hospital implementation in Indonesia and Thailand, we aim to gain insights, which will support future implementation.

Methods

The selection of criteria and their average weight were compared quantitatively across the MCDA-instruments developed in all four countries and settings. Implementation experiences from two case-examples were studied, which included (1) testing the instrument across a variety of drugs in seven hospitals in Thailand and (2) implementation in one specialty hospital in Indonesia. Semi-structured interviews were conducted via web-conferences with four diverse stakeholders in the pilot implementation projects in Thailand and Indonesia. The open responses were evaluated through qualitative content analysis and synthesis using grounded theory coding.

Results

Drivers for implementation were making ‘better’ decisions, achieving transparency and a rational selection process, reducing drug shortages, and assuring consistent quality. Challenges were seen on the technical level (definition or of criteria, scoring methods, access to data) or change-related challenges (resistance, perception of increased workload, lack of competencies or capabilities, lack of resources). The comparison of the MCDA instruments revealed high similarity, but also clear need for local adaptations in each specific case.

Conclusion

A set a of measures targeting challenges related to utility, methodology, data requirements, capacity building and training as well as the broader societal impact can help to overcome challenges in the implementation. Careful planning of implementation and organizational change is recommended for ensuring commitment and fit to local context and culture. Designing a collaborative change program for each application of MCDA-based purchasing will enable healthcare stakeholders to maximally benefit in terms of quality and effectiveness of care and access for patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00333-8.

The effects of quantity discounts on supply chain performance: Looking through the Bullwhip lens

Quantity discounts are a common pricing mechanism to stimulate large orders. We explore their impact on the dynamic behaviour of production and distribution systems by studying key operational and economic metrics. In a three-echelon supply chain, we observe that the discount generally increases the Bullwhip Effect, which especially harms the manufacturer. The discount also reduces the retailer's purchase costs, but increases its inventory- and capacity-related costs. A key trade-off thus emerges, which manifests itself through a U-shaped relationship between the total cost and the discount acceptance parameter. In the light of this trade-off, we discuss how key factors should affect the retailer's willingness to pursue the discount. We observe that managers that need to deal with tougher environmental conditions, such as high demand uncertainty and long lead times, should be less reluctant to increase orders up to the discount quantity. We also discuss in detail other valuable insights for professionals, both from the perspective of sellers and buyers.

Performance of India's national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state

Background

A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India’s decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme.

Methods

The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds – year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance.

Results

Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY.

Conclusion

PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.

Utilisation and financial protection for hospital care under publicly funded health insurance in three states in Southern India

BACKGROUND

Many LMICs have implemented Publicly Funded Health Insurance (PFHI) programmes to improve access and financial protection. The national PFHI scheme implemented in India for a decade has been recently modified and expanded to cover free hospital care for 500 million persons. Since increase in annual cover amount is one of the main design modifications in the new programme, the relevant policy question is whether such design change can improve financial protection for hospital care. An evaluation of state-specific PFHI programmes with vertical cover larger than RSBY can help answer this question. Three states in Southern India - Andhra Pradesh, Karnataka and Tamil Nadu have been pioneers in implementing PFHI with a large insurance cover.

METHODS

The current study was meant to evaluate the PFHI in above three states in improving utilisation of hospital services and financial protection against expenses of hospitalization. Two cross-sections from National Sample Survey's health rounds, the 60th round done in 2004 and the 71st round done in 2014 were analysed. Instrumental Variable method was applied to address endogeneity or the selection problem in insurance.

RESULTS

Enrollment under PFHI was not associated with increase in utilisation of hospital care in the three states. Private hospitals dominated the empanelment of facilities under PFHI as well as utilisation. Out of Pocket Expenditure and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PFHI in the three states. The size of Out of Pocket Expenditure was significantly greater for utilisation in private sector, irrespective of insurance enrollment.

CONCLUSION

PFHI in the three states used substantially larger vertical cover than national scheme in 2014. The three states are known for their good governance. Yet, the PFHI programmes in all three states failed in fulfilling their fundamental purpose. Increasing vertical cover of PFHI and using either 'Trusts' or Insurance-companies as purchasers may not give desired results in absence of adequate regulation. The study raises doubts regarding effectiveness of contracting under PFHIs to influence provider-behavior in the Indian context. Further research is required to find solutions for addressing gaps that contribute to poor financial outcomes for patients under PFHI.

Contraband Cigarette Purchasing from First Nation reserves in Ontario and Quebec: Findings from the 2002-2014 ITC Canada Survey

Backround: The availability of contraband cigarettes provides incentives for price-sensitive smokers to reduce their monetary costs of smoking. The objectives of this study were to examine whether Canadian smokers' geographic proximity to First Nations reserves and attempts to quit smoking influenced the likelihood of purchasing lower-cost cigarettes from reserves.

METHODS

Data were from the International Tobacco Control (ITC) Canada Survey, a prospective survey of Canadian adult smokers conducted from 2002 to 2014 using telephone and online interviewing methods. Analysis was restricted to smokers from Ontario (n=2105) and Quebec (n=1427) participating in at least one survey wave. Smokers' postal codes were used to calculate distance to the nearest reserve. Weighted logistic generalised estimating equations (GEE) regression examined the linear relationship between distance and the log odds of last purchasing cigarettes on reserve in each province. GEE models also examined the relationship between past-year quit attempts and the log odds of on-reserve purchasing.

RESULTS

Controlling for other factors, from 2002-2014, smokers from Ontario who lived 10 km closer to reserves than otherwise similar smokers had significantly higher odds of last purchasing on reserve (OR ranged from 1.16 to 1.65). Distance had little effect on smokers' purchasing behaviours in Quebec. Moreover, in Ontario, for every 10 km increase in distance, smokers who did not try to quit had significantly greater odds of purchasing from a reserve than smokers who tried to quit (p=0.002).

CONCLUSION

In order for tobacco taxation policies to achieve their maximal benefit, governments must limit potential sources of lower-cost cigarettes. Collaborative governance arrangements can ensure tobacco products sold on reserve to non-Indigenous people are appropriately taxed while allowing First Nations communities to keep the revenue generated by such taxes.

Wine glass size and wine sales: four replication studies in one restaurant and two bars

Objective

Previous research suggests that wine glass size affects sales of wine in bars, with more wine purchased when served in larger glasses. The current four studies, conducted in one restaurant (Studies 1 and 2) and two bars (Studies 3 and 4) in Cambridge, England, aim to establish the reproducibility of this effect of glass size on sales. A multiple treatment reversal design was used, involving wine being served in sequential fortnightly periods in different sized glasses of the same design (290 ml, 350 ml, and 450 ml). The primary outcome was daily wine volume (ml) sold.

Results

Restaurant: Daily wine volume sold was 13% (95% CI 2%, 24%) higher when served with 350 ml vs. 290 ml glasses in Study 1. A similar direction of effect was seen in Study 2 (6%; 95% CI − 1%, 15%). Bars: Daily wine volume sold was 21% (95% CI 9%, 35%) higher when served with 450 ml vs. 350 ml glasses in Study 3. This effect was not observed in Study 4 (− 7%, 95% CI − 16%, 3%). Meaningful differences were not demonstrated with any other glass comparison. These results partially replicate previous studies showing that larger glasses increase wine sales. Considerable uncertainty remains about the magnitude of any effect and the contexts in which it might occur.

Trial registration Study 1: ISRCTN17958895 (21/07/2017), Study 2: ISRCTN17097810 (29/03/2018), Study 3 and 4: ISRCTN39401124 (10/05/2018)

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4477-8) contains supplementary material, which is available to authorized users.

Reinforcer pathology: Common neural substrates for delay discounting and snack purchasing in prediabetics

Reinforcer pathology theory stipulates that individuals with both (a) high preference for smaller, immediate over larger, delayed rewards; and (b) high demand for unhealthy commodities are uniquely susceptible to poor health outcomes. Specifically, two behavioral economic tasks (delay discounting, assessing preference for smaller, immediate or larger, delayed rewards; and purchasing, assessing purchases of commodities over changes in price) have been independently associated with conditions such as overweight/obesity and problem substance use. In the present study, we examined possible shared neural regions involved in the processes of delay discounting and demand for snack foods in a prediabetic sample. Fifty-four participants completed both of these tasks. Conjunction between delay discounting and purchasing task results indicates substantial common neural substrates recruited during these two tasks, consistent with interpretations of executive control, interoception, and attention, in the prefrontal cortex, insula, and frontoparietal cortex (superior/middle frontal cortex and superior/inferior parietal lobules), respectively. Collectively, these results suggest possible neural substrates in which the two behavioral risk factors of reinforcer pathology may interact during real-world decision-making in prediabetes.

Spirits purchasing and marijuana use behaviors of risky drinkers in the state of Washington from 2014 to 2016

BACKGROUND

Few studies have evaluated alcoholic beverage purchasing behaviors, which are relevant to the design and effectiveness of alcoholic beverage control policies. Focusing on spirits purchasing among spirits drinkers, this study compares purchasing behaviors between risky and non-risky drinkers and across drinking patterns among those observed drinking at both levels.

METHODS

A rolling panel of 794 spirits drinkers in the state of Washington were surveyed between two and five times at 6-month intervals during 2014, 2015 and 2016 regarding their alcohol use, spirits purchasing and marijuana use frequency. Purchasing behaviors assessed for spirits were the frequency of purchasing and the travel time, unit cost, bottle size and store type from the respondents most recent purchase. Alcohol use was categorized at each measurement as risky or not using US NIAAA guidelines.

RESULTS

Risky drinkers were more likely to purchase spirits, purchase spirits more frequently, purchase larger spirits containers and use marijuana occasionally, but not frequently. Among drinkers who were risky only in some survey waves, during risky waves they were more likely to purchase more frequently, pay less per liter for spirits purchased, buy larger sized containers of spirits and use marijuana occasionally.

CONCLUSIONS

Drinkers chose to purchase lower cost spirits in larger containers when they were drinking more heavily compared to times when they were drinking within US low-risk guidelines. Findings also support complementarity between heavier drinking and marijuana use among spirits drinkers in a state with legal recreational marijuana sales.

Health financing in fragile and conflict-affected settings: What do we know, seven years on?

Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.

Evaluating the design and implementation of the whole systems integrated care programme in North West London: why commissioning proved (again) to be the weakest link

Background

Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions.

Methods

We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data.

Results

Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions.

Conclusions

Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Øvretveit’s cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4013-5) contains supplementary material, which is available to authorized users.

Low institutional trust in health insurers in Dutch health care

A central element of the 2006 health insurance reform in the Netherlands is strategic purchasing by health insurers. After a brief elaboration of the concept of trust this article discusses the trust of insured in the new purchasing role of health insurers. There are various indications of a trust problem or credible commitment problem in Dutch health care. Insured say to trust their own health insurer (specific trust) but also say to have little trust in the behaviour of health insurers in general(institutional trust). The article briefly explores four models to explain the trust problem: the lack-of information model, the anticompetition model, the pro-profession model and the political communication model. A critical analysis demonstrates that the 'objective ground' for low institutional trust is rather questionable. Low trust seems to be based more on perceptions than on the insurers' objective purchasing behaviour. The article ends with a discussion on some potential strategies to address the trust problem. Low institutional trust may be something insurers have to live with.

Perceptions of a healthier neighborhood food environment linked to greater fruit and vegetable purchases at small and non-traditional food stores

The aim of this study was to examine associations between perceived neighborhood food environments and food purchasing at small and non-traditional food stores. Intercept interviews of 661 customers were conducted in 105 small and non-traditional food stores. We captured (1) customer perceptions of the neighborhood food environment, (2) associations between customer perceptions and store-level characteristics, and (3) customers' perceptions and shopping behaviors. Findings suggest that customers with more favorable perceptions of the neighborhood food environment were more likely to purchase fruits and vegetables, despite no significant association between perceptions of the neighborhood and objectively measured store characteristics.

Qualitative analysis of national documents on health care services and pharmaceuticals` purchasing challenges: evidence from Iran

Background

Iranian health sector encountered many challenges in resource allocation and health service purchasing during the past decades, the aim of this study was to determine the main challenges of the present process of health service purchasing for national policymakers and other developing countries with the same setting.

Methods

It was a qualitative study carried out via the complete content analysis of all relevant national documents from 2007 to 2014. In order to retrieve the related documents, we searched the official websites related to the Ministry of Health and Medical Education, four main Iranian insurance organizations, the Health Committee of the Parliament Profile, strategic vice president’s site and Supreme Insurance Council. After recognition of documents, their credibility and authenticity were evaluated in terms of their publication or adjustment. For the analysis of documents, the four step-Scott method was used applying MAXQDA version 10.

Results

Findings illustrated that health service purchase challenges in the country can be classified in 6 main themes of policy-making, executive, intersectional, natural, legal and informational challenges with 26 subthemes. Furthermore, 5 themes of Basic Benefit Package, Reimbursement,Decision making, Technology and Contract are considered as the main Challenges in pharmaceutical purchasing area containing 13 relevant subthemes.

Conclusions

It seems that according to documents, Iran has faced many structural and procedural problems with the purchase of the best health interventions. So it is highly recommended to consider consequences derived from the present challenges and try to use these evidences in their policy making process to decrease the existed problems and move to better procurement of health interventions.

Strategic Purchasing in Practice: Comparing Ten European Countries

Strategic purchasing of health care services is widely recommended as a policy instrument. We conducted a review of literature of material drawn from the European Observatory on Health Systems and Policies Health Systems in Transition series, other European Observatory databases, and selected country-specific literature to augment the comparative analysis by providing the most recent healthcare trends in ten selected countries. There is little evidence of purchasing being strategic according to any of the established definitions. There is little or no literature suggesting that existing purchasing mechanisms in Europe deliver improved population health, citizen empowerment, stronger governance and stewardship, or develop purchaser organization and capacity. Strategic purchasing has not generally been implemented. Policymakers considering adopting strategic purchasing policies should be aware of this systemic implementation problem. Policymakers in systems with strategic purchasing built into policy should not assume that a purchasing system is strategic or that it is delivering any expected objectives. However, there are individual components of strategic purchasing that are worth pursuing and can provide benefits to health systems.

Bags, batteries and boxes: A qualitative interview study to understand how syringe drivers are adapted and used by healthcare staff

Syringe drivers are medical devices that are critical for end of life care. They deliver continuous medication over extended periods of time. Their design contributes to the quality of experience for both patients and healthcare professionals. Little research has been published about the factors that influence the usability of this type of equipment for frontline users (i.e. those in direct contact with patients) and how equipment gets introduced. Understanding how syringe drivers are used in practice can help improve the design of equipment. 27 semi-structured interviews were conducted across acute hospitals, community hospitals and hospices (4 organisations in total). All participating organisations used the same type of syringe driver. It was found that frontline staff needed to adapt this equipment to fit the circumstances of use. The analysis provided examples of this happening for aspects relating to the appearance of the device (bags), accessories (batteries) and security (the lockable box).

Access to Tobacco Among California High School Students: The Role of Family Members, Peers, and Retail Venues

PURPOSE

The purpose of the study was to determine from whom and where adolescents obtained tobacco, including cigarettes, e-cigarettes, and hookah.

METHODS

California adolescents (N = 772; 63.19% female; mean age = 16.13 years, SD = 1.61; 26.44% white, 22.12% Asian/Pacific Islander, 36.65% Hispanic, and 14.79% other) were surveyed about their access to different tobacco products.

RESULTS

Adolescents were significantly more likely to obtain tobacco from friends (54.9%) than family members or direct purchasing (p < .001). Smoke shops were the most common purchase location across products (44.3%), with adolescents significantly more likely to purchase hookah and e-cigarettes from smoke shops than gas stations, liquor stores, or drug stores (p < .02).

CONCLUSIONS

The effective characterization of tobacco access patterns is critical to the development of comprehensive tobacco control. By demonstrating peers and smoke shops as the primary social and retail outlets, this study identifies targets for the optimization of regulation and messaging aimed at reducing adolescents' access to tobacco.

Wine glass size and wine sales: a replication study in two bars

Objective

Wine glass size may influence perceived volume and subsequently purchasing and consumption. Using a larger glass to serve the same portions of wine was found to increase wine sales by 9.4% (95% CI 1.9, 17.5) in a recent study conducted in one bar. The current study aimed to replicate this previous work in two other bars using a wider range of glass sizes. To match the previous study, a repeated multiple treatment reversal design, during which wine was served in glasses of the same design but different sizes, was used. The study was conducted in two bars in Cambridge, England, using glass sizes of 300, 370, 510 ml (Bar 1) and 300 and 510 ml (Bar 2). Customers purchased their choice of a 750 ml bottle, or standard UK measures of 125, 175 or 250 ml of wine, each of which was served with the same glass.

Results

Bar 1 Daily wine volume (ml) purchased was 10.5% (95% CI 1.0, 20.9) higher when sold in 510 ml compared to 370 ml glasses; but sales were not significantly higher with 370 ml versus 300 ml glasses (6.5%, 95% CI −5.2, 19.6). Bar 2 Findings were inconclusive as to whether daily wine purchased differed when using 510 ml versus 300 ml glasses (−1.1%, 95% CI −12.6, 11.9). These results provide a partial replication of previous work showing that introducing larger glasses (without manipulating portion size) increases purchasing. Understanding the mechanisms by which wine glass size influences consumption may elucidate when the effect can be expected and when not.

Trial registration This study is a replication study, based on the procedure set out in the trial registration for the study that it attempts to replicate (ISRCTN registry: ISRCTN12018175)

How do health service professionals consider human factors when purchasing interactive medical devices? A qualitative interview study

We present findings of a UK study into how those involved in purchasing interactive medical devices go about evaluating usability, the challenges that arise, and opportunities for improvement. The study focused on procurement of infusion devices because these are used by various professionals across healthcare. A semi-structured interview study was carried out involving a range of stakeholders (20 in total) involved in or impacted by medical device procurement. Data was analysed using thematic analysis, a qualitative method designed to support the identification, analysis and reporting of patterns. In principle, health service purchasing was found to accommodate consideration of equipment usability. In practice, the evaluation process was driven primarily by engineering standards; assessment of local needs did not accommodate substantive assessment of usability; and choice was limited by the availability of equipment on the marketplace. We discuss ways in which purchasing could be improved through techniques that account for social circumstances.

Effects of procurement practices on quality of medical device or service received: a qualitative study comparing countries

Background

We know little about how procurement of a high-risk medical device (HRMD) affects clinical practice and outcomes. In health systems in high-income countries, and specifically those that maintain a national arthroplasty registry, procurement decisions are frequently guided by long-term clinical results, with the goal of ensuring at least standard quality of HRMDs. But in countries like Mexico, decision-making is often dominated by lowest acquisition price. We set out to study the impact of procurement for orthopaedic HRMDs on clinical procedures and outcomes.

Methods

We based our qualitative study on 59 in-depth interviews with stakeholders from Mexico, Switzerland, Germany, and UK: orthopaedic specialists, government officials, other experts, and social security system managers or administrators. We took a healthcare delivery approach to capturing and comparing factors that affected the regulations of HRMDs and procurement processes, and to understanding connections between procurement and clinical practice.

Results

Our findings demonstrate for procurement processes that the three European countries compared to Mexico don’t have similar concerns with regards to their procurement processes. Deficiencies of procurement regulations and practices identified from representatives in Mexico were almost absent in European countries. We identified three areas of deficiency: 1) HRMD regulations based on insufficiently robust clinical evidence (mainly noted by European countries); 2) Follow-up on Health Technology Assessments is inadequate (noted by Mexico) and methodology not always good enough (noted by European countries); and, 3) Lowest-acquisition price often guides procurement decisions and thus may not align with needs of clinical procedures (noted by Mexico and some European countries).

Conclusions

Procurement processes for orthopaedic HRMDs may have an impact on clinical procedures and outcomes. A favourable approach is one where orthopaedic specialists are parties to the procurement process, and post-market surveillance data informs decision-making. Actors in the procurement process can improve their impact on clinical procedures and outcomes by developing specific strategies that better align the needs of both, procurement and clinical procedures.

Effects of nutrient profiling and price changes based on NuVal® scores on food purchasing in an online experimental supermarket

OBJECTIVE

The goal of the present study was to apply experimental economic methods in an online supermarket to examine the effects of nutrient profiling, and differential pricing based on the nutrient profile, on the overall diet quality, energy and macronutrients of the foods purchased, and diet cost.

DESIGN

Participants were provided nutrient profiling scores or price adjustments based on nutrient profile scores while completing a hypothetical grocery shopping task. Prices of foods in the top 20 % of nutrient profiling scores were reduced (subsidized) by 25 % while those in the bottom 20 % of scores were increased (taxed) by 25 %. We evaluated the independent and interactive effects of nutrient profiling or price adjustments on overall diet quality of foods purchased as assessed by the NuVal® score, energy and macronutrients purchased and diet cost in a 2×2 factorial design.

SETTING

A large (>10 000 food items) online experimental supermarket in the USA.

SUBJECTS

Seven hundred and eighty-one women.

RESULTS

Providing nutrient profiling scores improved overall diet quality of foods purchased. Price changes were associated with an increase in protein purchased, an increase in energy cost, and reduced carbohydrate and protein costs. Price changes and nutrient profiling combined were associated with no unique benefits beyond price changes or nutrient profiling alone.

CONCLUSIONS

Providing nutrient profile score increased overall NuVal® score without a reduction in energy purchased. Combining nutrient profiling and price changes did not show an overall benefit to diet quality and may be less useful than nutrient profiling alone to consumers who want to increase overall diet quality of foods purchased.

Experimental analysis of the effect of taxes and subsides on calories purchased in an on-line supermarket

Taxes and subsidies are a public health approach to improving nutrient quality of food purchases. While taxes or subsidies influence purchasing, it is unclear whether they influence total energy or overall diet quality of foods purchased. Using a within subjects design, selected low nutrient dense foods (e.g. sweetened beverages, candy, salty snacks) were taxed, and fruits and vegetables and bottled water were subsidized by 12.5% or 25% in comparison to a usual price condition for 199 female shoppers in an experimental store. Results showed taxes reduced calories purchased of taxed foods (coefficient = -6.61, CI = -11.94 to -1.28) and subsidies increased calories purchased of subsidized foods (coefficient = 13.74, CI = 8.51 to 18.97). However, no overall effect was observed on total calories purchased. Both taxes and subsidies were associated with a reduction in calories purchased for grains (taxes: coefficient = -6.58, CI = -11.91 to -1.24, subsidies: coefficient = -12.86, CI = -18.08 to -7.63) and subsidies were associated with a reduction in calories purchased for miscellaneous foods (coefficient = -7.40, CI = -12.62 to -2.17) (mostly fats, oils and sugars). Subsidies improved the nutrient quality of foods purchased (coefficient = 0.14, CI = 0.07 to 0.21). These results suggest that taxes and subsidies can influence energy purchased for products taxed or subsidized, but not total energy purchased. However, the improvement in nutrient quality with subsidies indicates that pricing can shift nutritional quality of foods purchased. Research is needed to evaluate if differential pricing strategies based on nutrient quality are associated with reduction in calories and improvement in nutrient quality of foods purchased.

Effectively engaging the private sector through vouchers and contracting - A case for analysing health governance and context

Health systems of low and middle income countries in the Asia Pacific have been described as mixed, where public and private sector operate in parallel. Gaps in the provision of primary health care (PHC) services have been picked up by the private sector and led to its growth; as can an enabling regulatory environment. The question whether governments should purchase services from the private sector to address gaps in service provision has been fiercely debated. This purposive review draws evidence from systematic reviews, and additional published and grey literature, for input into a policy brief on purchasing PHC-services from the private sector for underserved areas in the Asia Pacific region. Additional published and grey literature on vouchers and contracting as mechanisms to engage the private sector was used to supplement the conclusions from systematic reviews. We analysed the literature through a policy lens, or alternatively, a 'bottom-up' approach which incorporates components of a realist review. Evidence indicates that both vouchers and contracting can improve health service outcomes in underserved areas. These outcomes however are strongly influenced by (1) contextual factors, such as roles and functions attributable to a shared set of key actors (2) the type of delivered services and community demand (3) design of the intervention, notably provider autonomy and trust (4) governance capacity and provision of stewardship. Examining the experience of vouchers and contracting to expand health services through engagement with private sector providers in the Asia Pacific found positive effects with regards to access and utilisation of health services, but more importantly, highlighted the significance of contextual factors, appropriate selection of mechanism for services provided, and governance arrangements and stewardship capacity. In fact, for governments seeking to engage the private sector, analysis of context and capacities are potentially a more useful frame than generalizable outcomes of effectiveness.

An approach to prioritization of medical devices in low-income countries: an example based on the Republic of South Sudan

Background

Efficient and evidence-based medical device and equipment prioritization is of particular importance in low-income countries due to constraints in financing capacity, physical infrastructure and human resource capabilities.

Methods

This paper outlines a medical device prioritization method developed in first instance for the Republic of South Sudan. The simple algorithm offered here is a starting point for procurement and selection of medical devices and can be regarded as a screening test for those that require more labour intensive health economic modelling.

Conclusions

A heuristic method, such as the one presented here, is appropriate for reaching many medical device prioritization decisions in low-income settings. Further investment and purchasing decisions that cannot be reached so simply require more complex health economic modelling approaches.

Electronic supplementary material

The online version of this article (doi:10.1186/s12962-014-0027-3) contains supplementary material, which is available to authorized users.

Socioeconomic differences in purchases of more vs. less healthy foods and beverages: analysis of over 25,000 British households in 2010

Socioeconomic inequalities in diet-related health outcomes are well-recognised, but are not fully explained by observational studies of consumption. We provide a novel analysis to identify purchasing patterns more precisely, based on data for take-home food and beverage purchases from 25,674 British households in 2010. To examine socioeconomic differences (measured by occupation), we conducted regression analyses on the proportion of energy purchased from (a) each of 43 food or beverage categories and (b) major nutrients. Results showed numerous small category-level socioeconomic differences. Aggregation of the categories showed lower SES groups generally purchased a greater proportion of energy from less healthy foods and beverages than those in higher SES groups (65% and 60%, respectively), while higher SES groups purchased a greater proportion of energy from healthier food and beverages (28% vs. 24%). At the nutrient-level, socioeconomic differences were less marked, although higher SES was associated with purchasing greater proportions of fibre, protein and total sugars, and smaller proportions of sodium. The observed pattern of purchasing across SES groups contributes to the explanation of observed health differences between groups and highlights targets for interventions to reduce health inequalities.