Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050.

BACKGROUND: The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020. METHODS: We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050. FINDINGS: In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7-8·8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5-0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0-25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied. INTERPRETATION: Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all. FUNDING: Bill & Melinda Gates Foundation.

Developing a Financing System to Support Public Health Infrastructure.

All people in the United States deserve the same level of public health protection, making it crucial that every health department across the country has a core set of foundational capabilities. Current research indicates an annual cost of $32 per person to support the foundational public health capabilities needed to promote and protect health for everyone across the nation. Yet national investment in public health capabilities is currently about $19 per person, leaving a $13-per-person gap in annual spending.To "create the conditions in which people can be as healthy as possible" and to protect national security, this gap must be filled. The Public Health Leadership Forum convened national experts in the public health, public policy, and other partner sectors to develop options for long-term, sustainable financing. The group aligned around core principles and criteria necessary to establish a sustainable financing structure.Informed by the work of the expert panel, the authors recommend a Public Health Infrastructure Fund for state, territorial, local, and tribal governmental public health, that would provide $4.5 billion of new, permanent resources needed to fully support core public health foundational capabilities.

What is the long term impact of voucher scheme on primary care? Findings from a repeated cross sectional study using propensity score matching.

BACKGROUND: Vouchers are increasingly used as a demand-side subsidy to reduce financial hardship and improve quality of services. Elderly Healthcare Voucher Scheme has been introduced by the Hong Kong Government since 2009 to provide subsidy to elderly aged 65 and above to visit ten different types of private primary care providers for curative, preventive and chronic disease management. Several enhancements have been made over the past few years. This paper (as part of an evaluation study of this unique healthcare voucher scheme) aims to assess the long term impact of the voucher scheme in encouraging the use of primary care services. METHODS: Two rounds of cross-sectional survey among elderly in Hong Kong were conducted in 2010 and 2016. Propensity score matching and analysis were used to compare changes in perception and usage of vouchers over time. RESULTS: 61.5% of respondents in 2016 agreed "the scheme encourages me to use more private primary care services", a significant increase from 36.2% in 2010. Among those who agreed in 2016, the majority thought the voucher scheme would encourage them to use acute services (90.3%) in the private sector, rather than preventive care (40.3%) and chronic disease management (12.2%). Respondents also reported that their current usual choice of care was visiting "both public and private doctors" (61.9%), representing a significant increase (up from 48.4%) prior to their use of voucher. CONCLUSIONS: The voucher scheme has encouraged the use of more private care services, particularly acute services rather than disease prevention or management of chronic disease. However, there needs to be caution that the untargeted and open-ended nature of voucher scheme could result in supply-induced demand which would affect long term financial sustainability. The dual utilization of health services in both the public and private sector may also compromise continuity and quality of care. The design of the voucher needs to be more specific, targeting prevention and chronic disease management rather than unspecified care which is mainly acute and episodic in order to maximize service delivery capacity as a whole for equitable access in universal health coverage and to contribute to a sustainable financing system.

Nobody Knew How Complicated: Constraining The President's Power To (Re)Shape Health Reform.

Beginning on inauguration day, President Trump has attempted an executive repeal of the Affordable Care Act. In doing so, he has tested the limits of presidential power. He has challenged the force of institutional and non-institutional constraints. And, ironically, he has helped boost public support for the ACA's central features. The first two sections of this article respectively consider the use of the President's tools to advance and to subvert health reform. The final two sections consider the forces constraining the administration's attempted executive repeal. I argue that the most important institutional constraint, thus far, is found in multifaceted actions by states - and not only blue states. I also highlight the force of public voices. Personal stories, public opinion, and 2018 election results - bolstered by presidential messaging - reflect growing support for government-grounded options and statutory coverage protections. Indeed, in a polarized time, "refine and revise" seems poised to supplant "repeal and replace" as the conservative focus countering liberal pressure for a common option grounded in Medicare.

The Royal College of Nursing's quest to improve recruitment.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses a recent report by the Royal College of Nursing calling for the Government to change the system of funding for nurse education.

Publicly funded clinical research in Canada.

Clinical research is funded by industry, governments, charities, and hospitals. It is important to know the economic commitment of the various funding bodies, but until now there has been no national source available which provides these data. We surveyed the major funders to provide such a measure. There is evidence that government and charity funding of medical research is a trigger for private sector research investment; therefore, tracking all sources of funding for clinical research will provide policy-makers with an overall picture of health research funding. These data support policy decision-making related to clinical research in Canada.

Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

Inter-provincial inequality of public health services in China: the perspective of local officials' behavior.

BACKGROUND: After economic reform, China experienced rising public health services inequality between the eastern developed and mid-west undeveloped provinces. The fiscal transfer payment system which aims to shape the disparities was considered inefficient. However, there are only a few studies that address the political reason when analyzing the inter-provincial public health services inequality. And the previous studies did not consider a possible non-linear relationship between the fiscal transfer payments and the inter-provincial public health services equalization. METHODS: This paper argues that the local officials' fanatical pursuit of local economic growth which driven by the Political Promotion Tournament and the polarized fiscal self-sufficiency (fiscal capacities) of local governments are responsible for the inter-provincial inequality of public health services and the inefficiency of fiscal transfer payments. By constructing panel threshold regression models with fiscal self-sufficiency of local governments as threshold variable, this study tries to empirically investigate the optimal level of the local governments' self-sufficiency at which the fiscal transfer payments can effectively promote equalization. RESULTS: Threshold effects exist between fiscal transfer payments and inter-provincial public health services equalization. The effects on inter-provincial public health services equalization show trends that first increase and then decrease as the fiscal self-sufficiency of local governments increases. And there exist a range of fiscal self-sufficiency between 29.236 and 43.765% or between 28.575 and 45.746% for local governments where the fiscal transfer payments can effectively achieve equalization. Currently, the vast majority of provinces in China remain in the ineffective regime where the fiscal transfer payments are inefficient in shaping inequality. CONCLUSIONS: This paper explains the reason of inequality in public health services and the inefficiency of fiscal transfer payment system from Chinese local officials' behavior aspect, and try to find out an effective solution by focusing on the local government's fiscal capacity. The effective way to narrow the inequality is to establish a flexible tax-sharing system to adjust local governments' fiscal capacities and give local governments with low fiscal self-sufficiency more fiscal resources. The new policy measures recently launched by Chinese central government coincide with our recommendations.

Title V Maternal and Child Health Services Block Grant Priority Needs and Linked Performance Measures: Current Patterns and Trends (2000-2015).

Objective As part of the Title V Maternal and Child Health (MCH) Services Block Grant, administered by the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau (MCHB), states are required to conduct a comprehensive needs assessment identifying MCH priorities every 5 years. The most current needs assessment (2015) occurred after a transformation of the program, in which a new performance measurement framework was created. This analysis examined current patterns and trends in state MCH priorities and selected performance measures to identify changing needs and inform technical support. Methods Multiple coders categorized: (1) state priority needs from 2000 to 2015 into focus areas and subcategories for examination of current, diminishing, and emerging needs; and (2) the selection of linked national and state performance measures in 2015 for all 59 states and jurisdictions. Results Between 2000 and 2015, the proportion of states with a need around pre- and inter-conception care increased from 19% to 66%. More states had needs in the breastfeeding subcategory (42%) compared with 20% of states or less in previous years. Fewer states had needs around data capacity than in past years. Emerging needs included supporting families/relationships. The most commonly selected national performance measures (NPMs) were around breastfeeding and well-woman visits. The state performance measures (SPMs) analysis also emphasized assets, with measures around community/context and positive development. Teen births and postpartum depression were areas where multiple states had SPMs. Conclusions for practice Increasing and emerging needs may help to inform technical assistance and future national measures for the Title V program.

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.

Comparison of the Financial and Operational Characteristics of For-Profit and Nonprofit Hospitals Receiving Federal Graduate Medical Education Payments, 2011-2020.

This study compares graduate medical education (GME) payments between nonprofit and for-profit hospitals between 2011 and 2020 to assess how hospitals value GME.

Congenital rubella syndrome: A brief review of public health perspectives.

Congenital rubella syndrome (CRS) is one of the most devastating congenital infections and yet the only one which is vaccine preventable and is a public health challenge for clinicians and policymakers across the developing world including India. The clinical manifestations of CRS include growth retardation, cardiac defects, cataracts, and hearing impairment. The World Health Organization (WHO) estimates that worldwide over 100,000 babies are born with CRS every year despite the availability of safe and inexpensive vaccines, thus highlighting the need for broader vaccination coverage programs. This article briefly reviews the importance of CRS, the proposed strategies for prevention by the WHO, and the "Rubella initiative" that Government of India is launching in view of the recognition of CRS as a significant problem in India.

Public health in England in 2016-the health of the public and the public health system: a review.

Background: This article describes the current state of the health of the public in England and the state of the public health professional service and systems. Sources of data: Data sources are wide ranging including the Global Burden of Disease, the Commonwealth Fund and Public Health England reports. Areas of agreement: There is a high burden of preventable disease and unacceptable inequalities in England. There is considerable expectation that there are gains to be made in preventing ill health and disability and so relieving demand on healthcare. Areas of controversy: Despite agreement on the need for prevention, the Government has cut public health budgets by a cumulative 10% to 2020. Public health professionals broadly supportive of remaining in the EU face an uphill battle to retain health, workplace and environmental protections following the 'Leave' vote. Growing points and areas timely for developing research: There is revitalized interest in air pollution. Extreme weather events are testing response and organizational skills of public health professionals and indicating the need for greater advocacy around climate change, biodiversity and protection of ecological systems. Planetary health and ecological public health are ideas whose time has certainly come.

[Old and New Public Health Structures in Germany - Plenary Lecture of the Forum Future Public Health, Berlin 2016]. / Alte und neue Strukturen von Public Health in Deutschland.

Basic structures serving public health in Germany in the second decade of the 21st century are described. They are related to the governmental public health grant programs of the late 20th century and the successful re-introduction of public health competencies and capacities at universities and colleges. Structures under direct governmental responsibility, public law self-government and in the non-governmental for-profit and not-for-profit sector are described. Future challenges are sketched and a networked, three-dimensional model of research and development, politics and practice is suggested.

Do Austrian "INTEGRI (integrated care) projects" comply with international definitions and concepts?

One of the biggest challenges for European healthcare systems is the fragmentation of care. To overcome this challenge, integrated care (IC) approaches have been recently implemented. To further improve this method, current and past projects must be monitored and evaluated. However, since the definition of IC is very indistinct and varies significantly in literature, key elements have to be defined. The study design selected was a mixed-methods study that includes two approaches: a systematic literature review and qualitative content analysis of the data provided by the Ludwig Boltzmann Institute. Nine key elements of IC projects were identified in the literature review and subsequently compared with the main features coded from previous INTEGRI applications. The results showed that 41 of the applications presented seven or more criteria in their official submission form. The conclusion of the results can be drawn as a justification and validation of the INTEGRI criteria. Although the results are positive on the whole, three recommendations on possible improvements are given.

Federal Policies and Programs to Expand Employment Services Among Individuals with Serious Mental Illnesses.

Previous studies suggest that providing employment services to individuals with serious mental illnesses can help them obtain competitive, real-world employment. However, these services are still not easily accessible to this population. This paper provides a brief summary of recent federal initiatives that may influence widespread implementation of employment services. While there is an increasing recognition of the need to remove barriers and provide supported employment services to individuals with mental illnesses, a wide-spread coordination across Federal polices, financing and regulatory changes are necessary to promote measurable and lasting effects on the broad availability of employment services among this population.

Expected Impact of Health Care Reform on the Organization and Service Delivery of Publicly Funded Addiction Health Services.

Little is known about how the Affordable Care Act (ACA) will be implemented in publicly funded addiction health services (AHS) organizations. Guided by a conceptual model of implementation of new practices in health care systems, this study relied on qualitative data collected in 2013 from 30 AHS clinical supervisors in Los Angeles County, California. Interviews were transcribed, coded, and analyzed using a constructivist grounded theory approach with ATLAS.ti software. Supervisors expected several potential effects of ACA implementation, including increased use of AHS services, shifts in the duration and intensity of AHS services, and workforce professionalization. However, supervisors were not prepared for actions to align their programs' strategic change plans with policy expectations. Findings point to the need for health care policy interventions to help treatment providers effectively respond to ACA principles of improving standards of care and reducing disparities.