An extended cost-effectiveness analysis of schizophrenia treatment in India under universal public finance.

BACKGROUND: Schizophrenia remains a priority condition in mental health policy and service development because of its early onset, severity and consequences for affected individuals and households. AIMS AND METHODS: This paper reports on an 'extended' cost-effectiveness analysis (ECEA) for schizophrenia treatment in India, which seeks to evaluate through a modeling approach not only the costs and health effects of intervention but also the consequences of a policy of universal public finance (UPF) on health and financial outcomes across income quintiles. RESULTS: Using plausible values for input parameters, we conclude that health gains from UPF are concentrated among the poorest, whereas the non-health gains in the form of out-of-pocket private expenditures averted due to UPF are concentrated among the richest income quintiles. Value of insurance is the highest for the poorest quintile and declines with income. CONCLUSIONS: Universal public finance can play a crucial role in ameliorating the adverse economic and social consequences of schizophrenia and its treatment in resource-constrained settings where health insurance coverage is generally poor. This paper shows the potential distributional and financial risk protection effects of treating schizophrenia.

Epithelial neoplasia in Drosophila entails switch to primitive cell states.

Only select cell types in an organ display neoplasia when targeted oncogenically. How developmental lineage hierarchies of these cells prefigure their neoplastic propensities is not yet well-understood. Here we show that neoplastic Drosophila epithelial cells reverse their developmental commitments and switch to primitive cell states. In a context of alleviated tissue surveillance, for example, loss of Lethal giant larvae (Lgl) tumor suppressor in the wing primordium induced epithelial neoplasia in its Homothorax (Hth)-expressing proximal domain. Transcriptional profile of proximally transformed mosaic wing epithelium and functional tests revealed tumor cooperation by multiple signaling pathways. In contrast, lgl(-) clones in the Vestigial (Vg)-expressing distal wing epithelium were eliminated by cell death. Distal lgl(-) clones, however, could transform when both tissue surveillance and cell death were compromised genetically and, alternatively, when the transcription cofactor of Hippo signaling pathway, Yorkie (Yki), was activated, or when Ras/EGFR signaling was up-regulated. Furthermore, transforming distal lgl(-) clones displayed loss of Vg, suggesting reversal of their terminal cell fate commitment. In contrast, reinforcing a distal (wing) cell fate commitment in lgl(-) clones by gaining Vg arrested their neoplasia and induced cell death. We also show that neoplasia in both distal and proximal lgl(-) clones could progress in the absence of Hth, revealing Hth-independent wing epithelial neoplasia. Likewise, neoplasia in the eye primordium resulted in loss of Elav, a retinal cell marker; these, however, switched to an Hth-dependent primitive cell state. These results suggest a general characteristic of "cells-of-origin" in epithelial cancers, namely their propensity for switch to primitive cell states.

Enabling cross-country learning and exchange to support universal health coverage implementation.

As countries transition from external assistance while pursuing ambitious plans to achieve universal health coverage (UHC), there is increasing need to facilitate knowledge sharing and learning among them. Country-led and country-owned knowledge management is foundational to sustainable, more equitable external assistance for health and is a useful complement to more conventional capacity-building modalities provided under external assistance. In the context of external assistance, few initiatives use country-to-country sharing of practitioner experiences, and link learning to receiving guidance on how to adapt, apply and sustain policy changes. Dominant knowledge exchange processes are didactic, implicitly assuming static technical needs, and that practitioners in low- and middle-income countries require problem-specific, time-bound solutions. In reality, the technical challenges of achieving UHC and the group of policymakers involved continuously evolve. This paper aims to explore factors which are supportive of experience-based knowledge exchange between practitioners from diverse settings, drawing from the experience of the Joint Learning Network (JLN) for UHC-a global network of practitioners and policymakers sharing experiences about common challenges to develop and implement knowledge products supporting reforms for UHC-as an illustration of a peer-to-peer learning approach. This paper considers: (1) an analysis of JLN monitoring and evaluation data between 2020 and 2023 and (2) a qualitative inquiry to explore policymakers' engagement with the JLN using semi-structured interviews (n = 14) with stakeholders from 10 countries. The JLN's experience provides insights to factors that contribute to successful peer-to-peer learning approaches. JLN relies on engaging a network of practitioners with diverse experiences who organically identify and pursue a common learning agenda. Meaningful peer-to-peer learning requires dynamic, structured interactions, and alignment with windows of opportunity for implementation that enable rapid response to emerging and timely issues. Peer-to-peer learning can facilitate in-country knowledge sharing, learning and catalyse action at the institutional and health system levels.

Variation in cost and performance of routine immunisation service delivery in India.

A comprehensive understanding of the costs of routine vaccine delivery is essential for planning, budgeting and sustaining India's Universal Immunisation Programme. India currently allocates approximately US$25 per child for vaccines and operational costs. This budget is prepared based on historical expenditure data as information on cost is not available. This study estimated the cost of routine immunisation services based on a stratified, random sample of 255 public health facilities from 24 districts across seven states-Bihar, Gujarat, Kerala, Meghalaya, Punjab, Uttar Pradesh and West Bengal. The economic cost for the fiscal year 2013-2014 was measured by adapting an internationally accepted approach for the Indian context. Programme costs included the value of personnel, vaccines, transport, maintenance, training, cold chain equipment, building and other recurrent costs. The weighted average national level cost per dose delivered was US$2.29 including vaccine costs, and the cost per child vaccinated with the third dose of diphtheria-pertussis-tetanus (DPT) vaccine (a proxy for full immunisation) was US$31.67 (at 2017 prices). There was wide variation in the weighted average state-level cost per dose delivered inclusive of vaccine costs (US$1.38 to US$2.93) and, for the cost per DTP3 vaccinated child (US$20.08 to US$34.81). Lower costs were incurred by facilities and districts that provided the largest number of doses of vaccine. Out of the total cost, the highest amount (57%) was spent on personnel. This costing study, the most comprehensive conducted to date in India, provides evidence, which should help improve planning and budgeting for the national programme. The budget generally considers financial costs, while this study focused on economic costs. For using this study's results for planning and budgeting, the collected data can be used to extract the relevant financial costs. Variation in cost per dose and doses administered across facilities, districts and states need to be further investigated to understand the drivers of cost and measure the efficiency of service delivery.

Supported and unsupported claims in medicinal drug advertisements in Indian medical journals.

The study assessed 292 supported and unsupported claims in 102 medicinal drug advertisements across 15 Indian medical journals published in 2009. WHO ethical criteria for medicinal drug promotion were applied. None of the advertisements satisfied all the WHO criteria. Safe prescribing information on major adverse drug reactions, contraindications and warnings was provided in only 19 advertisements. Of 292 drug claims, only 80 (27%) were supported with reference(s), of which only 7 (9%) claims were unambiguous, or well substantiated with references. 14 references quoted did not substantiate the claim and 15 constituted weak scientific evidence. Superlatives like "tested" "trusted" "guarantees success" and "matchless safety" were used without evidence to substantiate such claims. Stronger enforcement mechanisms are necessary to ensure reliable drug information in pharmaceutical advertisements.