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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., Competing Interests: Declaration of interests D McCracken's position was supported in part through the Wellcome Trust, and by the Department of Health and Social Care using UK aid funding managed by the Fleming Fund. R Ancuceanu reports consulting fees from AbbVie and AstraZeneca; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Sandoz, AbbVie, and Braun Medical; and support for attending meetings or travel from AbbVie and AstraZeneca, all outside the submitted work. M Ausloos and C Herteliu report grants or contracts from the Romanian National Authority for Scientific Research and Innovation (CNDS-UEFISCDI), project number PN-III-P4-ID-PCCF-2016-0084, outside the submitted work. C Herteliu reports grants or contracts from CNDS-UEFISCDI, project number PN-III-P2-2.1-SOL-2020-2-0351, outside the submitted work. S Bhaskar reports an unpaid leadership or fiduciary role in a board, society, committee or advocacy group, with the Rotary Club of Sydney Board of Directors, outside the submitted work. R Busse reports grants or contracts from Berlin University Alliance (COVID pre-exploration project), outside the submitted work. S M S Islam reports grants or contracts from National Health and Medical Research Council (NHMRC) and the National Heart Foundation of Australia, all outside the submitted work. K Krishan reports non-financial support from UGC Centre of Advanced Study phase II, Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. M J Postma reports grants or contacts from Merck Sharp & DDohme, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Bayer, Bristol Myers Squibb, AstraZeneca, Sanofi, IQVIA, BioMerieux, WHO, EU, Seqirus, FIND, Antilope, DIKTI, LPDP, and Budi; consulting fees from Merk Sharp & Dohme, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Quintiles, Bristol Myers Squibb, Astra Zeneca, Sanofi, Novartis, Pharmerit, IQVIA, and Seqirus; participation on a Data Safety Monitoring Board or Advisory Board to Asc Academics as Advisor; and stock or stock options in Health-Ecore and PAG, all outside the submitted work. M G Shrime reports grants or contracts from the Iris O'Brien Foundation; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Brightsight speakers; and leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid with Pharos Global Health Advisors as a board member. J A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, Two labs, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, MedIQ, UBM, Trio Health, Medscape, WebMD, and Practice Point communications, and the National Institutes of Health and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings and travel from OMERACT; leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, with OMERACT as a member of the steering committee, with the US Food and Drug Administration Arthritis Advisory Committee, with the Veterans Affairs Rheumatology Field Advisory Committee as a member, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a Director and Editor; stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, and Charlotte's Web Holdings; and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals, all outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

To promote postpandemic recovery, many countries have adopted economic packages that include fiscal, monetary, and financial policy measures; however, the effects of these policies may not be known for several years or more. There is an opportunity for decision makers to learn from past policies that facilitated recovery from other disease outbreaks, crises, and natural disasters that have had a devastating effect on economies around the world. To support the development of the United Nations Research Roadmap for COVID-19 Recovery, this review examined and synthesized peer-reviewed studies and gray literature that focused on macroeconomic policy responses and multilateral coalition strategies from past pandemics and crises to provide a map of the existing evidence. We conducted a systematic search of academic and gray literature databases. After screening, we found 22 records that were eligible for this review. The evidence found demonstrates that macroeconomic and multilateral coalition strategies have various impacts on a diverse set of countries and populations. Although the studies were heterogeneous in nature, most did find positive results for macroeconomic intervention policies that addressed investments to strengthen health and social protection systems, specifically cash and unconventional/nonstandard monetary measures, in-kind transfers, social security financing, and measures geared toward certain population groups.

Background: The US 21st Century Cures Act provided $7.5 billion in grant funding to states and territories for evidence-based responses to the opioid epidemic. Currently, little is known about optimal strategies for sustaining these programs beyond this start-up funding., Methods: Using an inductive, conventional content analysis, we conducted key informant interviews with former and current state leaders (n = 16) about barriers/facilitators to sustainment and strategies for sustaining time-limited grants., Results: Financing and reimbursement, service integration, and workforce capacity were the most cited barriers to sustainment. Status in state government structure, public support, and spending flexibility were noted as key facilitators. Effective levers to increase chances for sustainment included strong partnerships with other state agencies, workforce and credentialing changes, and marshalling advocacy through public awareness campaigns., Conclusions: Understanding the strategies that leaders have successfully used to sustain programs in the past can inform how to continue future time-limited, grant-funded initiatives.

Purpose: Many health systems face challenges such as rising costs and lacking quality, both of which can be addressed by improving the integration of different health care sectors and professions. The purpose of this viewpoint is to present the German health care Innovation Fund (IF) initiated by the Federal Government to support the development and diffusion of integrated health care., Design/methodology/approach: This article describes the design and rationale of the IF in detail and provides first insights into its limitations, acceptance and implementation by relevant stakeholders., Findings: In its first period, the IF offered € 1.2 billion as start-up funding for model implementation and evaluation over a period of four years (2016-2019). This period was recently extended to a second round until 2024, offering € 200 million a year as from 2020. The IF is triggering the support of relevant insurers for the development of new integrated care models. In addition, strict evaluation requirements have led to a large number of health service research projects which assess structural and process improvements and thus enable evidence-based policy decisions., Originality/value: This article is the first of its kind to present the German IF to the international readership. The IF is a political initiative through which to foster innovations and promote integrated health care., (© Emerald Publishing Limited.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare. Provenance and peer review: Not commissioned; externally peer reviewed.

The Government of Thailand was prompt to launch social and economic measures to mitigate the effects on the general population following lockdown measures to counter coronavirus disease 2019 (COVID-19). However, sex workers were one of the vulnerable groups who were unable to access state support. A rapid survey of sex workers in Thailand showed that almost all had become unemployed and lost their income as a consequence of the lockdown, restrictions on international flights into the country and the closure of entertainment venues. Most were unable to cover the costs of food and shelter for themselves and their dependents. COVID-19 had also disrupted testing and treatment for sexually transmitted infections and HIV services for sex workers. As in other countries, community-based organizations were essential to providing an immediate, short-term COVID-19 response for sex workers. Also as in other countries, the pandemic has demonstrated that many people's health and well-being depends on very fragile foundations. This presents a clear opportunity to build back better by committing to a longer-term vision for the overall societal inclusion of sex workers. Thailand should advocate for decriminalization of sex work and ensure sex workers are entitled to equal labour rights and inclusion in the government social protection programme. Progress in innovative government initiatives aimed at ending HIV stigma and discrimination show how structural change can come about through harnessing community-based organizations. In turn, HIV services for sex workers need to expand and incorporate targeted interventions to reduce sex workers' occupational susceptibility to COVID-19., Competing Interests: None

Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

To solve information asymmetry, we adopted the principal-agent framework to design the incentive mechanisms between the remanufacturer and the collector in the construction and demolition (C&D) waste-recycling industry. By using the model of reciprocity, we analyzed how the entities' behavioral motives affect their decisions in terms of the incentive mechanisms. The findings showed that the collector responds to their perception of the remanufacturer's intentions. If the perception is positive, they will make more effort in the collection work. If not, less effort will be put forth. Most importantly, we found that reciprocity helps to save the remanufacturer cost in the incentive mechanisms and makes the collector choose a higher effort level in the collection work. This finding showed that reciprocity serves to solve information asymmetry. By conducting a numerical simulation, we found that although a high subsidy policy can achieve rapid improvement of recycling-supply-chain performance, it is inefficient in maintaining friendly cooperation between the remanufacturer and the collector.

Background: Saudi Arabia has invested heavily in its health care system by establishing health care infrastructures to improve health of the nation. However, it remains to be seen whether it is efficient and effective in providing health care services needed. Primary health care, which is the basis of universal health coverage, needs to be assessed on its performance, challenges and future opportunities to serve the Saudi Arabian population., Aims: This review aimed to identify challenges within the Saudi Arabian health care system with a focus on primary health care services, and to analyse the interrelated factors in order to suggest remedial reforms to further strengthen and improve the health care system., Methods: A narrative review of previous studies and governmental reports was undertaken to extract, analyse, synthesize and report the findings., Results: The review found a number of key areas for improvement in the primary health care system. These areas include: the scope, structure, infrastructure, financing, increased demand, increased costs and workforce capacity. Other critical challenges include inequitable access to health services, quality and safety of services, the growing burden of chronic diseases, lack of an effective information system, management and leadership issues, and gaps in the referral system., Conclusion: The Saudi Arabian health care system needs comprehensive reform with a focus on primary health care., (Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Objective: The need to align investments in health research and development (R&D) with public health needs is one of the most important public health challenges in Japan. We examined the alignment of disease-specific publicly competitive R&D funding to the disease burden in the country., Methods: We analyzed publicly available data on competitive public funding for health in 2015 and 2016 and compared it to disability-adjusted life year (DALYs) in 2016, which were obtained from the Global Burden of Disease (GBD) 2017 study. Their alignment was assessed as a percentage distribution among 22 GBD disease groups. Funding was allocated to the 22 disease groups based on natural language processing, using textual information such as project title and abstract for each research project, while considering for the frequency of information., Results: Total publicly competitive funding in health R&D in 2015 and 2016 reached 344.1 billion JPY (about 3.0 billion USD) for 32,204 awarded projects. About 49.5% of the funding was classifiable for disease-specific projects. Five GDB disease groups were significantly and relatively well-funded compared to their contributions to Japan's DALY, including neglected tropical diseases and malaria (funding vs DALY = 1.7% vs 0.0%, p<0.01) and neoplasms (28.5% vs 19.2%, p<0.001). In contrast, four GDB disease groups were significantly under-funded, including cardiovascular diseases (8.0% vs 14.8%, p<0.001) and musculoskeletal disorders (1.0% vs 11.9%, p<0.001). These percentages do not include unclassifiable funding., Conclusions: While caution is necessary as this study was not able to consider public in-house funding and the methodological uncertainties could not be ruled out, the analysis may provide a snapshot of the limited alignment between publicly competitive disease-specific funding and the disease burden in the country. The results call for greater management over the allocation of scarce resources on health R&D. DALYs will serve as a crucial, but not the only, consideration in aligning Japan's research priorities with the public health needs. In addition, the algorithms for natural language processing used in this study require continued efforts to improve accuracy., Competing Interests: The authors have declared that no competing interests exist.

Background : A corruption event in 2009 led to changes in how donors supported the Zambian health system. Donor funding was withdrawn from the district basket mechanism, originally designed to pool donor and government financing for primary care. The withdrawal of these funds from the pooled financing mechanism raised questions from Government and donors regarding the impact on primary care financing during this period of aid volatility. Objectives : To examine the budgets and actual expenditure allocated from central Government to the district level, for health, in Zambia from 2006 to 2017 and determine trends in funding for primary care. Methods : Financial data were extracted from Government documents and adjusted for inflation. Budget and expenditure for the district level over the period 2006 to 2017 were disaggregated by programmatic area for analysis. Results : Despite the withdrawal of donor funding from the district basket after 2009, funding for primary care allocated to the district level more than doubled from 2006 to 2017. However, human resources accounted for this increase. The operational grant, on the other hand, declined. Conclusion : The increase in the budget allocated to primary care could be an example of 'reverse fungibility', whereby Government accounted for the gap left by donors. However, the decline in the operational grant demonstrates that this period of aid volatility continued to have an impact on how primary care was planned and financed, with less flexible budget lines most affected during this period. Going forward, Government and donors must consider how funding is allocated to ensure that primary care is resilient to aid volatility; and that the principles of aid effectiveness are prioritised to continue to provide primary health care and progress towards achieving health for all.

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.

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.

Background: Recognizing that quality family planning services should include services to help clients who want to become pregnant, the objective of our analysis was to examine the distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States., Methods: A nationally representative sample of publicly funded clinics was surveyed in 2013-2014 (n = 1615). Clinic administrators were asked about several clinical services and screenings related to achieving pregnancy: basic infertility services, reproductive life plan assessment, screening for body mass index, screening for sexually transmitted diseases, provision of natural family planning services, infertility treatment, and primary care services. The percentage of clinics offering each of these services was compared by Title X funding status; prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated after adjusting for clinic characteristics., Results: Compared to non-Title X clinics, Title X clinics were more likely to offer reproductive life plan assessment (adjusted PR [aPR], 1.62; 95% CI, 1.42-1.84), body mass index screening for men (aPR, 1.10; 95% CI, 1.01-1.21), screening for sexually transmitted diseases (aPRs ranged from 1.21 to 1.37), and preconception health care for men (aPR, 1.10; 95% CI, 1.01-1.20). Title X clinics were less likely to offer infertility treatment (aPR, 0.55; 95% CI, 0.40-0.74) and primary care services (aPR, 0.74; 95% CI, 0.68-0.80) and were just as likely to offer basic infertility services, preconception health care services for women, natural family planning, and body mass index screening in women., Conclusions: The availability of selected services related to achieving pregnancy differed by Title X status. A follow-up assessment after publication of national family planning recommendations is underway., (Published by Elsevier Inc.)

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.

The adoption of the shared prosperity goal by the World Bank in 2013 and Sustainable Development Goal 10, on inequality, by the United Nations in 2015 should strengthen the focus of development interventions and cooperation on the income growth of the bottom 40 percent of the income distribution. This paper contributes to the incipient literature on within-country allocations of development institutions and assesses the geographic targeting of World Bank projects to the bottom 40 percent. Bivariate correlations between the allocation of project funding approved over 2005-14 and the geographical distribution of the bottom 40 as measured by survey income or consumption data are complemented by regressions with population and other potential factors affecting the within-country allocations as controls. The correlation analysis shows that, of the 58 countries in the sample, 41 exhibit a positive correlation between the shares of the bottom 40 and World Bank funding, and, in almost half of these, the correlation is above 0.5. Slightly more than a quarter of the countries, mostly in Sub-Saharan Africa, exhibit a negative correlation. The regression analysis shows that, once one controls for population, the correlation between the bottom 40 and World Bank funding switches sign and becomes significant and negative on average. This is entirely driven by Sub-Saharan Africa and not observed in the other regions. Hence, the significant and positive correlation in the estimations without controlling for population suggests that World Bank project funding is concentrated in administrative areas in which more people live (including the bottom 40) rather than in poorer administrative areas. Furthermore, capital cities receive disproportionally high shares of World Bank funding on average., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Lodewijk Smets was a staff member of the Independent Evaluation Group (IEG) of the World Bank at the time this paper was written. Renzo Massari was a consultant for the World Bank. Željko Bogetić is a staff member of the Independent Evaluation Group (IEG) of the World Bank. We confirm that these associations in no way influenced our analysis. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

The high cost of dental education and consequent loan burdens contribute to the shortage of pediatric dental providers in rural areas (RAs). Economic incentives are meant to recruit practitioners to RAs. The aim of this study was to assess the ability of government subsidized loan repayment programs (GSLRPs) to recruit pediatric specialists to practice in RAs. A 26-item questionnaire was emailed to all 921 pediatric dental residents across the U.S. in 2015 for a cross-sectional study of factors influencing their choice of practice location. The instrument included information about GSLRPs, enabling the study to serve as a quasi-experiment on the level of funding needed to make GSLRPs effective. A total of 169 residents responded, for an 18% response rate; 74% of respondents were women and 86% had student loan debt. Among the respondents, 40.6% said they would like to practice in RAs, but only 4.1% actually intended to do so. Over one-third initially reported interest in GSLRPs for practicing in RAs. However, after being informed that the average GSLRP is $30,000 annually, one-third of those lost interest. Although 14.2% said no amount would convince them to consider practice in an RA, over half (53.3%) indicated willingness to consider it if the GSLRP were $40,000-$60,000. These results suggest that current GSLRP levels are insufficient to induce pediatric dentists to practice in RAs.

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.

Portugal has faced an economic and financial crisis that began circa FY2009 and whose effects are still ongoing. In FY2011, the Portuguese state and the European triumvirate - composed of the European Commission, the International Monetary Fund, and the European Central Bank - signed the Memoranda of Understanding. This troika agreement aimed to improve the operational efficiency of public services. This crisis had a considerable impact on the Portuguese citizens' life and productivity, as well as on the public health care system. Cuts over public expenditures have been made to reduce the risk of noncompliance with budgetary targets, despite their potential impact on quality and access to health care services. We analyzed the main policies and measures undertaken by the Portuguese Ministry of Health with respect to the bailout program associated with the troika agreement. Then, we focused on the budgetary cuts-related risks over the social performance of the care system. Evidence suggests that structural reforms in the health care sector in the troika period had positive effects in terms of drugs administration and consumption, on the one hand, and secondary care expenditures reduction, on the other hand. Nonetheless, we observed some divestitures on infrastructures and the worsening of access to health care services.

Public support of training in firms corresponds to the long-term importance of the quality of human capital in the competitiveness of firms and nations. Thus, the EU supports such training via the European Social Fund (ESF). The evaluation community evaluates the support by using either qualitative or quantitative methods. The simultaneous application of these two approaches is rare. The purpose of this paper is to combine quantitative (counterfactual impact evaluation) and qualitative (qualitative comparative analysis) methods in order to fill the methodological gap. Based on the combination of both approaches, it explores their strengths, complementarity and disadvantages to evaluate public support for employee training in the Czech Republic. The combination of methods makes it possible to identify not only the impacts but also their causes. Linking the ESF support to corporate competitiveness is crucial for demonstrating the effectiveness of public spending., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: There is sufficient evidence that psychosocial stimulation (PS) benefits children's neurocognitive behavior, however, there is no information on how it works when delivered through an Unconditional Cash Transfer (UCT) platform for poor rural population in developing countries. The objective of this study is to measure effects of adding PS for children of lactating mothers enrolled to receive UCT with health education (HE) on neurocognitive behavior of children in rural Bangladesh., Methods: The study will be conducted at 11 unions of Ullapara sub-district in Bangladesh. The study is a cluster randomized controlled trial with three-arms; (i) PS and UCT with HE (ii) UCT with HE and iii) Comparison arm. The cluster will be considered as an old Ward of a Union, the lowest tier of local government system in rural Bangladesh. There are three old Wards in a union. These three clusters will be randomized to one of the three arms. Similarly, randomization will be done for each 11 Unions and then 11 clusters will be assigned to an arm. Eighteen participants will be recruited from each cluster randomly (n = 196 in each arm). The intervention designed for one year includes UCT with HE for the poor as a safety net program in rural Bangladesh with or without PS. An age-based curriculum of PS is already available for Bangladeshi children and this will be administered by trained local women; play leaders (PL) in intervention clusters. The government of Bangladesh is providing UCT of taka 500 ($6.25) as maternity allowance per month with HE. The primary outcomes will be cognitive, motor and language composite scores measured by Bayley-III and behavior using Wolke's behavior rating scale. The secondary outcomes will be children and mothers' growth, family food security status, health seeking behavior, mothers' depressive symptoms and self-esteem and violence against mothers., Discussion: The study will provide a unique opportunity to assess an integrated early childhood development intervention using UCT platform to mitigate developmental delays in poor vulnerable children of rural Bangladesh., Trial Registration Number: ClinicalTrials.gov NCT03281980, registered on September 13, 2017.

Objective: To measure inequalities in the distributions of selected healthcare resources and outcomes in Ethiopia from 2000 to 2015., Design: A panel data analysis was performed to measure inequalities in distribution of healthcare workforce, infrastructure, outcomes and finance, using secondary data., Setting: The study was conducted across 11 regions in Ethiopia., Participants: Regional population and selected healthcare workforce., Outcomes Measured: Aggregate Theil and Gini indices, changes in inequalities and elasticity of healthcare resources., Results: Despite marked inequality reductions over a 16 year period, the Theil and Gini indices for the healthcare resources distributions remained high. Among the healthcare workforce distributions, the Gini index (GI) was lowest for nurses plus midwives (GI=0.428, 95% CI 0.393 to 0.463) and highest for specialist doctors (SPDs) (GI=0.704, 95% CI 0.652 to 0.756). Inter-region inequality was the highest for SPDs (95.0%) and the lowest for health officers (53.8%). The GIs for hospital beds, hospitals and health centres (HCs) were 0.592(95% CI 0.563 to 0.621), 0.460(95% CI 0.404 to 0.517) and 0.409(95% CI 0.380 to 0.439), respectively. The interaction term was highest for HC distributions (47.7%). Outpatient department visit per capita (GI=0.349, 95% CI 0.321 to 0.377) and fully immunised children (GI=0.307, 95% CI 0.269 to 0.345) showed inequalities; inequality in the under 5 years of age mortality rate increased overtime (P=0.048). Overall, GI for government health expenditure (GHE) was 0.596(95% CI 0.544 to 0.648), and the estimated relative GHE share of the healthcare workforce and infrastructure distributions were 46.5% and 53.5%, respectively. The marginal changes in the healthcare resources distributions were towards the advantaged populations., Conclusion: This study revealed high inequalities in healthcare resources in favour of the advantaged populations which can hinder equal access to healthcare and the achievements of healthcare outcomes. The government should strengthen monitoring mechanisms to address inequalities based on the national healthcare standards., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

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.

Scientist administrators at the National Institutes of Health fall into two categories: program officers and scientific review officers. Program officers provide advice to applicants and grantees, make funding recommendations, oversee grantees' research progress, and facilitate research opportunities in emerging areas of science. Scientific review officers oversee all aspects of the initial (peer) review of grant applications., (Copyright © 2018 Cold Spring Harbor Laboratory Press; all rights reserved.)

Background: Public funding for medical research in Germany is primarily provided by the German Research Foundation (DFG) and the Federal Ministry of Education and Research (BMBF). The aim of this study was to analyze the amount of national public funding for medical research on predominant causes of death in Germany, cardiovascular diseases and neoplasms, in relation to the burden of these diseases in Germany., Methods: Three evaluators categorized medical research projects funded by the DFG or BMBF between 2010 and 2012 into the categories "Diseases of the circulatory system" (with subgroups "Ischemic heart diseases", "Heart failure" and "Cerebrovascular diseases") and "Neoplasms". The total amount of public funding by the national agencies was analyzed in relation to the burden of disease for the respective disease condition., Results: Information on national public funding for medical research of 2091 million euros was available; of those, 246.8 million euros (11.8%) were categorized being spent for research on "Neoplasms", 118.4 million euros (5.7%) for research on "Diseases of the circulatory system". This results in 362.08 euros per case of death, 16.58 euros per year of life lost (YLL) and 16.04 euros per disability-adjusted life year (DALY) for "Neoplasms" and in 113.44 euros per case of death, 8.05 euros per YLL and 7.17 euros per DALY for "Diseases of the circulatory system"., Conclusions: In Germany, research on cardiovascular diseases receives a lower share of national public funding for medical research compared to oncological research. These results are comparable to other European countries.

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.

Background: Referrals to other medical services are central to healthcare, including family planning service providers; however, little information exists on the nature of referral practices among health centers that offer family planning., Materials and Methods: We used a nationally representative survey of administrators from 1,615 publicly funded health centers that offered family planning in 2013-14 to describe the use of six referral practices. We focused on associations between various health center characteristics and frequent use of three active referral practices., Results: In the prior 3 months, a majority of health centers (73%) frequently asked clients about referrals at clients' next visit. Under half (43%) reported frequently following up with referral sources to find out if their clients had been seen. A third (32%) of all health centers reported frequently using three active referral practices. In adjusted analysis, Planned Parenthood clinics (adjusted odds ratio 0.55) and hospital-based clinics (AOR 0.39) had lower odds of using the three active referral practices compared with health departments, and Title X funding status was not associated with the outcome. The outcome was positively associated with serving rural areas (AOR 1.39), having a larger client volume (AOR 3.16), being a part of an insurance network (AOR 1.42), and using electronic health records (AOR 1.62)., Conclusions: Publicly funded family planning providers were heavily engaged in referrals. Specific referral practices varied widely and by type of care. More assessment of these and other aspects of referral systems and practices is needed to better characterize the quality of care.

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.

Clinical trials are important to ensure that patients and society benefit from healthcare interventions. Among the Danish public research investments in medical sciences the main part of funding is given to preclinical and translational research, and less than ten per cent is given to clinical trials. This imbalance may have negative consequences for patients and society, because public investment in clinical trials is likely to ensure broader availability of tested interventions independent of diseases, patient groups, caregivers and clinical settings.