Scaling of buccal mass growth and muscle activation determine the duration of feeding behaviours in the marine mollusc Aplysia californica.

The mechanical forces experienced during movement and the time constants of muscle activation are important determinants of the durations of behaviours, which may both be affected by size-dependent scaling. The mechanics of slow movements in small animals are dominated by elastic forces and are thus quasistatic (i.e. always near mechanical equilibrium). Muscular forces producing movement and elastic forces resisting movement should scale identically (proportional to mass2/3), leaving the scaling of the time constant of muscle activation to play a critical role in determining behavioural duration. We tested this hypothesis by measuring the duration of feeding behaviours in the marine mollusc Aplysia californica whose body sizes spanned three orders of magnitude. The duration of muscle activation was determined by measuring the time it took for muscles to produce maximum force as A. californica attempted to feed on tethered inedible seaweed, which provided an in vivo approximation of an isometric contraction. The timing of muscle activation scaled with mass0.3. The total duration of biting behaviours scaled identically, with mass0.3, indicating a lack of additional mechanical effects. The duration of swallowing behaviour, however, exhibited a shallower scaling of mass0.17. We suggest that this was due to the allometric growth of the anterior retractor muscle during development, as measured by micro-computed tomography (micro-CT) scans of buccal masses. Consequently, larger A. californica did not need to activate their muscles as fully to produce equivalent forces. These results indicate that muscle activation may be an important determinant of the scaling of behavioural durations in quasistatic systems.

Linking Public Health and Public Safety Data on Co-occurring Disorders Among Adults in Hawaii's Criminal Justice System.

To better understand the behavioral health treatment needs of adults involved in the criminal justice system and to improve the continuum of services provided to this vulnerable population, Hawaii initiated a data linkage project that connects substance use and mental health data from the state Department of Public Safety with behavioral health treatment data from the state Department of Health for the State of Hawaii. Specifically, this linkage project begins to examine behavioral health treatment levels recommended by the criminal justice system and Hawaii State Hospital inpatient psychiatric admissions. We provide a preliminary summary on individuals who were both involved in the criminal justice system and received court-ordered inpatient psychiatric treatment and outline data governance procedures, future directions, and practice recommendations.

Living Alone and Homelessness as Predictors of 30-Day Potentially Preventable Hospital Readmission.

INTRODUCTION: The effect of social factors on health care outcomes is widely recognized. Health care systems are encouraged to add social and behavioral measures to electronic health records (EHRs), but limited research demonstrates how to leverage this information. We assessed 2 social factors collected from EHRs - social isolation and homelessness - in predicting 30-day potentially preventable readmissions (PPRs) to hospital. METHODS: EHR data were collected from May 2015 through April 2017 from inpatients at 2 urban hospitals on O'ahu, Hawai'i (N = 21,274). We performed multivariable logistic regression models predicting 30-day PPR by living alone versus living with others and by documented homelessness versus no documented homelessness, controlling for relevant factors, including age group, race/ethnicity, sex, and comorbid conditions. RESULTS: Among the 21,274 index hospitalizations, 16.5% (3,504) were people living alone and 11.2% (2,385) were homeless; 4.2% (899) hospitalizations had a 30-day PPR. In bivariate analysis, living alone did not significantly affect likelihood of a 30-day PPR (16.6% [3,376 hospitalizations] without PPR vs 14.4% [128 hospitalizations] with PPR; P = .09). However, documented homelessness did show a significant effect on the likelihood of 30-day PPR in the bivariate analysis (11.1% [2,259 hospitalizations] without PPR vs 14.1% [126 hospitalizations] with PPR; P = .006). In multivariable models, neither living alone nor homelessness was significantly associated with PPR. Factors that were significantly associated with PPR were comorbid conditions, discharge disposition, and use of an assistive device. CONCLUSION: Homelessness predicted PPR in descriptive analyses. Neither living alone nor homelessness predicted PPR once other factors were controlled. Instead, indicators of physical frailty (ie, use of an assistive device) and medical complexity (eg, hospitalizations that required assistive care post-discharge, people with a high number of comorbid conditions) were significant. Future research should focus on refining, collecting, and applying social factor data obtained through acute care EHRs.

Pandemic risk: how large are the expected losses?

There is an unmet need for greater investment in preparedness against major epidemics and pandemics. The arguments in favour of such investment have been largely based on estimates of the losses in national incomes that might occur as the result of a major epidemic or pandemic. Recently, we extended the estimate to include the valuation of the lives lost as a result of pandemic-related increases in mortality. This produced markedly higher estimates of the full value of loss that might occur as the result of a future pandemic. We parametrized an exceedance probability function for a global influenza pandemic and estimated that the expected number of influenza-pandemic-related deaths is about 720 000 per year. We calculated that the expected annual losses from pandemic risk to be about 500 billion United States dollars - or 0.6% of global income - per year. This estimate falls within - but towards the lower end of - the Intergovernmental Panel on Climate Change's estimates of the value of the losses from global warming, which range from 0.2% to 2% of global income. The estimated percentage of annual national income represented by the expected value of losses varied by country income grouping: from a little over 0.3% in high-income countries to 1.6% in lower-middle-income countries. Most of the losses from influenza pandemics come from rare, severe events.

Il est nécessaire d'investir davantage dans la préparation contre les grandes épidémies et les pandémies. Les arguments en faveur de cet investissement s'appuient en grande partie sur les estimations des pertes au niveau du revenu national que pourrait entraîner une grande épidémie ou une pandémie. Récemment, nous avons élargi ces estimations pour y inclure la valeur des pertes faisant suite à des hausses de mortalité dues à des pandémies. Cela a donné des estimations nettement plus élevées de la valeur totale de la perte que pourrait occasionner une future pandémie. Nous avons paramétré une fonction de probabilité de dépassement pour une pandémie mondiale de grippe et avons estimé que le nombre escompté de décès dus à cette pandémie de grippe était d'environ 720 000 par an. Nous avons calculé que les pertes annuelles découlant du risque de pandémie représentaient environ 500 milliards de dollars des États-Unis, soit 0,6% du revenu mondial par an. Cette estimation rejoint (dans la fourchette inférieure) celles du Groupe d'experts intergouvernemental sur l'évolution du climat quant à la valeur des pertes dues au réchauffement de la planète, qui vont de 0,2% à 2% du revenu mondial. Le pourcentage estimé du revenu national annuel représenté par la valeur escomptée des pertes variait selon la catégorie de revenu des pays: d'un peu plus de 0,3% dans les pays à revenu élevé à 1,6% dans les pays à revenu intermédiaire-tranche inférieure. La plupart des pertes découlant de pandémies de grippe sont dues à des événements rares et graves.

Hay una necesidad no satisfecha de invertir más en la preparación para grandes epidemias y pandemias. Los argumentos a favor de dicha inversión se basan, en gran parte, en las estimaciones de las pérdidas en los ingresos nacionales que podrían darse como resultado de una gran epidemia o pandemia. Recientemente, ampliamos el cálculo para incluir la valoración de las vidas perdidas como resultado del aumento de la mortalidad relacionado con la pandemia. Esto dio como resultado unas estimaciones notablemente más altas del valor de la pérdida que podría resultar de una futura pandemia. Hemos parametrizado una función de probabilidad de excedencia para una pandemia de gripe mundial y estimado que el número esperado de muertes causadas por una pandemia de gripe es de aproximadamente 720 000 por año. Calculamos que las pérdidas anuales esperadas del riesgo de pandemia son de unos 500 000 millones de dólares estadounidenses, o el 0,6 % de los ingresos mundiales, por año. Esta estimación se encuentra dentro, pero cerca del mínimo, de las estimaciones del Panel Intergubernamental del Cambio Climático sobre el valor de las pérdidas por el calentamiento global, que oscilan entre el 0,2 % y el 2 % de los ingresos globales. El porcentaje estimado de los ingresos nacionales anuales representado por el valor esperado de las pérdidas varió según la agrupación de ingresos del país: de poco más del 0,3 % en los países con ingresos altos al 1,6 % en los países con ingresos medios o bajos. La mayoría de las pérdidas por pandemias de gripe provienen de casos raros y severos.

Multi-criteria decision analysis: of politics, policy entrepreneurs, and processes.

Multi-criteria decision analysis (MCDA) has the potential to increase the consistency, transparency and rigour with which these criteria inform decisions. Political context is relevant not only as a motivation for turning to MCDA but also the context in which MCDA can be successfully implemented. A policy entrepreneur can spearhead the creation of a process to carry out MCDA and can help to create and build the capacity of a public institution that observes and convenes this process, an institution that has legal authority to carry out such a function.

Priority setting in health: development and application of a multi-criteria algorithm for the population of New Zealand's Waikato region.

BACKGROUND: Priority setting in a climate of diverse needs and limited resources is one of the most significant challenges faced by health care policymakers. This paper develops and applies a comprehensive multi-criteria algorithm to help determine the relative importance of health conditions that affect a defined population. METHODS: Our algorithm is implemented in the context of the Waikato District Health Board (WDHB) in New Zealand, which serves approximately 10% of the New Zealand population. Strategic priorities of the WDHB are operationalized into five criteria along which the algorithm is structured-scale of disease, household financial impact of disease, health equity, cost-effectiveness, and multimorbidity burden. Using national-level data and published literature from New Zealand, the World Health Organization, and other high-income Commonwealth countries, 25 health conditions in Waikato are identified and mapped to these five criteria. These disease-criteria mappings are weighted with data from an ordered choice survey administered to the general public of the Waikato region. The resulting output of health conditions ranked in order of relative importance is validated against an explicit list of health concerns, provided by the survey respondents. RESULTS: Heart disease and cancerous disorders are assigned highest priority rankings according to both the algorithm and the survey data, suggesting that our model is aligned with the primary health concerns of the general public. All five criteria are weighted near-equal across survey respondents, though the average health equity preference score is 9.2% higher for Maori compared to non-Maori respondents. Older respondents (50 years and above) ranked issues of multimorbidity 4.2% higher than younger respondents. CONCLUSIONS: Health preferences of the general population can be elicited using ordered-choice surveys and can be used to weight data for health conditions across multiple criteria, providing policymakers with a practical tool to inform which health conditions deserve the most attention. Our model connects public health strategic priorities, the health impacts and financial costs of particular health conditions, and the underlying preferences of the general public. We illustrate a practical approach to quantifying the foundational criteria that drive public preferences, for the purpose of relevant, legitimate, and evidence-based priority setting in health.

Reducing costs at the end of life through provider incentives for hospice care: A retrospective cohort study.

BACKGROUND: Costs of medical care have been found to be highest at the end of life. AIM: To evaluate the effect of provider reimbursement for hospice care on end-of-life costs. DESIGN: The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life. SETTING/PARTICIPANTS: A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan. RESULTS: Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%. CONCLUSION: By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.

Fiscal transfers based on inputs or outcomes? Lessons from the Twelfth and Thirteenth Finance Commission in India.

BACKGROUND: There is limited empirical evidence about the efficacy of fiscal transfers for a specific purpose, including for health which represents an important source of funds for the delivery of public services especially in large populous countries such as India. OBJECTIVE: To examine two distinct methodologies for allocating specific-purpose centre-to-state transfers, one using an input-based formula focused on equity and the other using an outcome-based formula focused on performance. MATERIALS AND METHODS: We examine the Twelfth Finance Commission (12FC)'s use of Equalization Grants for Health (EGH) as an input-based formula and the Thirteenth Finance Commission (13FC)'s use of Incentive Grants for Health (IGH) as an outcome-based formula. We simulate and replicate the allocation of these two transfer methodologies and examine the consequences of these fiscal transfer mechanisms. RESULTS: The EGH placed conditions for releasing funds, but states varied in their ability to meet those conditions, and hence their allocations varied, eg, Madhya Pradesh received 100% and Odisha 67% of its expected allocation. Due to the design of the IGH formula, IGH allocations were unequally distributed and highly concentrated in 4 states (Manipur, Sikkim, Tamil Nadu, Nagaland), which received over half the national IGH allocation. DISCUSSION: The EGH had limited impact in achieving equalization, whereas the IGH rewards were concentrated in states which were already doing better. Greater transparency and accountability of centre-to-state allocations and specifically their methodologies are needed to ensure that allocation objectives are aligned to performance.

Activation of ganglion cells and axon bundles using epiretinal electrical stimulation.

Epiretinal prostheses for treating blindness activate axon bundles, causing large, arc-shaped visual percepts that limit the quality of artificial vision. Improving the function of epiretinal prostheses therefore requires understanding and avoiding axon bundle activation. This study introduces a method to detect axon bundle activation on the basis of its electrical signature and uses the method to test whether epiretinal stimulation can directly elicit spikes in individual retinal ganglion cells without activating nearby axon bundles. Combined electrical stimulation and recording from isolated primate retina were performed using a custom multielectrode system (512 electrodes, 10-µm diameter, 60-µm pitch). Axon bundle signals were identified by their bidirectional propagation, speed, and increasing amplitude as a function of stimulation current. The threshold for bundle activation varied across electrodes and retinas, and was in the same range as the threshold for activating retinal ganglion cells near their somas. In the peripheral retina, 45% of electrodes that activated individual ganglion cells (17% of all electrodes) did so without activating bundles. This permitted selective activation of 21% of recorded ganglion cells (7% of expected ganglion cells) over the array. In one recording in the central retina, 75% of electrodes that activated individual ganglion cells (16% of all electrodes) did so without activating bundles. The ability to selectively activate a subset of retinal ganglion cells without axon bundles suggests a possible novel architecture for future epiretinal prostheses.NEW & NOTEWORTHY Large-scale multielectrode recording and stimulation were used to test how selectively retinal ganglion cells can be electrically activated without activating axon bundles. A novel method was developed to identify axon activation on the basis of its unique electrical signature and was used to find that a subset of ganglion cells can be activated at single-cell, single-spike resolution without producing bundle activity in peripheral and central retina. These findings have implications for the development of advanced retinal prostheses.

Aligning Funding and Need for Family Planning: A Diagnostic Methodology.

With limited international resources for family planning, donors must decide how to allocate their funds to different countries. How can a donor for family planning decide whether countries are adequately prioritized for funding? This article proposes an ordinal ranking framework to identify under-prioritized countries by rank-ordering countries by their need for family planning and separately rank-ordering them by their development assistance for family planning. Countries for which the rank of the need for family planning is lower than the rank of its funding are deemed under-prioritized. We implement this diagnostic methodology to identify under-prioritized countries that have a higher need but lower development assistance for family planning. This approach indicates whether a country is receiving less compared to other countries with similar levels of need.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study.

BACKGROUND: Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. METHODS: We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. RESULTS: During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. CONCLUSIONS: Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

The impact of internal displacement on child mortality in post-earthquake Haiti: a difference-in-differences analysis.

BACKGROUND: The Haiti earthquake in 2010 resulted in 1.5 million internally displaced people (IDP), yet little is known about the impact of displacement on health. In this study, we estimate the impact of displacement on infant and child mortality and key health-behavior mechanisms. METHODS: We employ a difference-in-differences (DID) design with coarsened exact matching (CEM) to ensure comparability among groups with different displacement status using the 2012 Haiti Demographic and Health Survey (DHS). The participants are 21,417 births reported by a nationally representative sample of 14,287 women aged 15-49. The main independent variables are household displacement status which includes households living in camps, IDP households (not in camps), and households not displaced. The main outcomes are infant and child mortality; health status (height-for-age, anemia); uptake of public health interventions (bed net use, spraying against mosquitoes, and vaccinations); and other conditions (hunger; cholera). RESULTS: Births from the camp households have higher infant mortality (OR = 2.34, 95 % CI 1.15 to 4.75) and child mortality (OR = 2.34, 95 % CI 1.10 to 5.00) than those in non-camp IDP households following the earthquake. These odds are higher despite better access to food, water, bed net use, mosquito spraying, and vaccines among camp households. CONCLUSIONS: IDP populations are heterogeneous and households that are displaced outside of camps may be self-selected or self-insured. Meanwhile, even households not displaced by a disaster may face challenges in access to basic necessities and health services. Efforts are needed to identify vulnerable populations to provide targeted assistance in post-disaster relief.

Strategic Provider Behavior Under Global Budget Payment with Price Adjustment in Taiwan.

Global budget payment is one of the most effective strategies for cost containment, but its impacts on provider behavior have not been explored in detail. This study examines the theoretical and empirical role of global budget payment on provider behavior. The study proposes that global budget payment with price adjustment is a form of common-pool resources. A two-product game theoretic model is derived, and simulations demonstrate that hospitals are expected to expand service volumes, with an emphasis on products with higher price-marginal cost ratios. Next, the study examines the early effects of Taiwan's global budget payment system using a difference-in-difference strategy and finds that Taiwanese hospitals exhibited such behavior, where the pursuit of individual interests led to an increase in treatment intensities. Furthermore, hospitals significantly increased inpatient service volume for regional hospitals and medical centers. In contrast, local hospitals, particularly for those without teaching status designation, faced a negative impact on service volume, as larger hospitals were better positioned to induce demand and pulled volume away from their smaller counterparts through more profitable services and products such as radiology and pharmaceuticals.

China's role as a global health donor in Africa: what can we learn from studying under reported resource flows?

BACKGROUND: There is a growing recognition of China's role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China's engagement as a donor with that of more traditional global health donors. METHODS: Using newly released data from AidData on China's development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000-2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China's activities to projects from traditional donors using data from the OECD's Development Assistance Committee (DAC) Creditor Reporting System. RESULTS: Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China's contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries. CONCLUSIONS: China is an important global health donor to Africa but contrasts with traditional DAC donors through China's focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China's approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

Understanding China's shifting priorities and priority-setting processes in development assistance for health.

Over the past two decades, China has become a distinctive and increasingly important donor of development assistance for health (DAH). However, little is known about what factors influence China's priority-setting for DAH. In this study, we provide an updated analysis of trends in the priorities of Chinese DAH and compare them to comparable trends among OECD Development Assistance Committee (DAC) donors using data from the AidData's Global Chinese Development Finance Dataset (2000-2017, version 2.0) and the Creditor Reporting System (CRS) database (2000-2017). We also analyse Chinese medical aid exports before and after the start of the COVID-19 pandemic using a Chinese Aid Exports Database. We further explore the potential factors influencing China's shifting priority-setting processes by reviewing Chinese official documents following Walt and Gilson's policy analysis framework (context-actors-process-content) and by testing our conjectures empirically. We find that China has become an important DAH donor to most regions if measured using project value, including but not limited to Africa. China has prioritized aid to African and Asian countries as well as to CRS subsectors that are not prioritized by DAC donors, such as medical services and basic health infrastructure. Chinese quarterly medical aid exports almost quintupled after the start of the COVID-19 pandemic. Noticeably, China has allocated more attention to Asia, eye diseases and infectious disease outbreaks over time. In contrast, the priority given to malaria has declined over the same period. Regarding factors affecting priority shifts, the outbreaks of SARS and Ebola, the launch of the Belt and Road Initiative and the COVID-19 pandemic appear to be important milestones in the timeline of Chinese DAH. Unlike stereotypes of China as a 'lone wolf' donor, our analysis suggests multilateral processes are influential in informing and setting Chinese DAH priorities.

Political and economic aspects of the transition to universal health coverage.

Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people. The third is an increase in the share of health spending that is pooled rather than paid out-of-pocket by households. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care--in other cases it is mobilised in the form of contributions to mandatory insurance schemes. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage. This paper describes common patterns in countries that have successfully provided universal access to health care and considers how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health.

Organizational Formation for Priority Setting: Historical Perspectives and Thematic Analysis of India's Health Technology Assessment Agency.

Countries pursuing universal health coverage must set priorities to determine which benefits to add to a national health program, but the roles that organizations play are less understood. This article investigates the case of the formation of an organization with a mandate for choice of technology for public health interventions and priorities, the Health Technology Assessment India. First, we narrate a chronology of agenda setting and adoption of national policy for organizational formation drawing on historical documentation, publicly available literature, and lived experiences from coauthors. Next, we conduct a thematic analysis that examines windows of opportunity, enabling factors, barriers and conditions, roles of stakeholders, messaging and framing, and specific administrative and bureaucratic tools that facilitated organization formation. This case study shows that organizational formation relied on the identification of multiple champions with sufficient seniority and political authority across a wide group of organizations, forming a coalition of broad base support, who were keen to advance health technology assessment policy development and organizational placement or formation. The champions in turn could use their roles for policy decisions that used private and public events to raise priority and commitment to the decisions, carefully considered organizational placement and formation, and developed the network of organizations for the generation of technical evidence and capacity building for health technology assessment, strengthened by international networks and organizations with financing, expertise, and policymaker relationships.

International Partnerships to Develop Evidence-informed Priority Setting Institutions: Ten Years of Experience from the International Decision Support Initiative (iDSI).

All health systems must set priorities. Evidence-informed priority-setting (EIPS) is a specific form of systematic priority-setting which involves explicit consideration of evidence to determine the healthcare interventions to be provided. The international Decision Support Initiative (iDSI) was established in 2013 as a collaborative platform to catalyze faster progress on EIPS, particularly in low- and middle-income countries. This article summarizes the successes, challenges, and lessons learned from ten years of iDSI partnering with countries to develop EIPS institutions and processes. This is a thematic documentary analysis, structured by iDSI's theory of change, extracting successes, challenges, and lessons from three external evaluations and 19 internal reports to funders. We identified three phases of iDSI's work-inception (2013-15), scale-up (2016-2019), and focus on Africa (2019-2023). iDSI has established a global platform for coordinating EIPS, advanced the field, and supported regional networks in Asia and Africa. It has facilitated progress in securing high-level commitment to EIPS, strengthened EIPS institutions, and developed capacity for health technology assessments. This has resulted in improved decisions on service provision, procurement, and clinical care. Major lessons learned include the importance of sustained political will to develop EIPS; a clear EIPS mandate; inclusive governance structures appropriate to health financing context; politically sensitive and country-led support to EIPS, taking advantage of policy windows for EIPS reforms; regional networks for peer support and long-term sustainability; utilization of context appropriate methods such as adaptive HTA; and crucially, donor-funded global health initiatives supporting and integrating with national EIPS systems, not undermining them.

State health insurance and out-of-pocket health expenditures in Andhra Pradesh, India.

In 2007 the state of Andhra Pradesh in southern India began rolling out Aarogyasri health insurance to reduce catastrophic health expenditures in households 'below the poverty line'. We exploit variation in program roll-out over time and districts to evaluate the impacts of the scheme using difference-in-differences. Our results suggest that within the first nine months of implementation Phase I of Aarogyasri significantly reduced out-of-pocket inpatient expenditures and, to a lesser extent, outpatient expenditures. These results are robust to checks using quantile regression and matching methods. No clear effects on catastrophic health expenditures or medical impoverishment are seen. Aarogyasri is not benefiting scheduled caste and scheduled tribe households as much as the rest of the population.