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Abstract Background Indonesia implemented one of the world’s largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%. Methods This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February–April 2018 and August–October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted. Results The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities. Conclusions This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line.

The Health Intervention and Technology Assessment Program (HITAP) was established in 2007. This article highlights 15 lessons from over 15 years of experience, noting five achievements about what HITAP has done well, five areas that it is currently working on, and five aims for work in the future. HITAP built capacity for HTA and linked research to policy and practice in Thailand. With collaborators from academic and policy spheres, HITAP has mobilized regional and global support, and developed global public goods to enhance the field of HTA. HITAP’s semi-autonomous structure has facilitated these changes, though they have not been without their challenges. HITAP aims to continue its work on HTA for public health interventions and disinvestments, effectively engaging with stakeholders and strategically managing its human resources. Moving forward, HITAP will develop and update global public goods on HTA, work on emerging topics such as early HTA, address issues in digital health, real-world evidence and equity, support HTA development globally, particularly in low-income settings, and seek to engage more effectively with the public. HITAP seeks to learn from its experience and invest in the areas identified so that it can grow sustainably. Its journey may be relevant to other countries and institutions that are interested in developing HTA programs.

Abstract Background Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. Methods We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. Results Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less ‘pro-poor’ while private clinics became more ‘pro-rich’ after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). Conclusions Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals’ pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.

Advanced gynecologic cancers have historically lacked effective treatment options. Recently, immune checkpoint inhibitors (ICIs) have been approved by the US Food and Drug Administration for the treatment of cervical cancer and endometrial cancer, offering durable responses for some patients. In addition, many immunotherapy strategies are under investigation for the treatment of earlier stages of disease or in other gynecologic cancers, such as ovarian cancer and rare gynecologic tumors. While the integration of ICIs into the standard of care has improved outcomes for patients, their use requires a nuanced understanding of biomarker testing, treatment selection, patient selection, response evaluation and surveillance, and patient quality of life considerations, among other topics. To address this need for guidance, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline. The Expert Panel drew on the published literature as well as their own clinical experience to develop evidence- and consensus-based recommendations to provide guidance to cancer care professionals treating patients with gynecologic cancer.

Melanomas from gynecologic sites (MOGS) are rare and have poor survival. MicroRNAs (miRs) regulate gene expression and are dysregulated in cancer. We hypothesized that MOGS would display unique miR and mRNA expression profiles. The miR and mRNA expression profile in RNA from formalin fixed, paraffin embedded vaginal melanomas (relative to vaginal mucosa) and vulvar melanomas (relative to cutaneous melanoma) were measured with the Nanostring Human miRNA assay and Tumor Signaling mRNA assay. Differential patterns of expression were identified for 21 miRs in vaginal and 47 miRs in vulvar melanoma (fold change >2, p

Summary: Background: In 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 – 2019. Methods: This study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 – 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index. Findings: Around a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 – 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 – 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019. Interpretation: The declining progressivity of the overall health financing system between 2015 – 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected. Funding: This study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.

Chemotherapy has been used to inhibit cancer growth for decades, but emerging evidence shows it can affect the tumor stroma, unintentionally promoting cancer malignancy. After treatment of primary tumors, remaining drugs drain via lymphatics. Though all drugs interact with the lymphatics, we know little of their impact on them. Here, we show a previously unknown effect of platinums, a widely used class of chemotherapeutics, to directly induce systemic lymphangiogenesis and activation. These changes are dose-dependent, long-lasting, and occur in healthy and cancerous tissue in multiple mouse models of breast cancer. We found similar effects in human ovarian and breast cancer patients whose treatment regimens included platinums. Carboplatin treatment of healthy mice prior to mammary tumor inoculation increased cancer metastasis as compared to no pre-treatment. These platinum-induced phenomena could be blocked by VEGFR3 inhibition. These findings have implications for cancer patients receiving platinums and may support the inclusion of anti-VEGFR3 therapy into treatment regimens or differential design of treatment regimens to alter these potential effects.

Abstract Background Establishing a workforce capable of meeting population needs is contingent on evaluation that can inform sound policy and planning. Health workforce evaluation has traditionally relied on health labour market analysis and workload estimations. To date, competency analysis has not been included in national health workforce evaluation, despite that fact that the findings may go far in guiding decisions around workforce composition, optimisation and education and training. This case study sought to assess the feasibility and perceived added value of integrating competency analysis into national rehabilitation workforce evaluation, and to determine how competency analysis can shape rehabilitation workforce planning. The findings of the case study can be used to explore the integration of competency analysis in the evaluation of other health-related occupational groups. Methods Participant observation was complemented by key informant interviews with experts engaged in the national rehabilitation workforce evaluation in Poland. These experts represented stakeholders in policy, education, research, clinical practice and professional associations. Results The results indicated that competency analysis can be feasibly integrated into national rehabilitation workforce evaluation, particularly when implementation is supported through the use of online platforms. However, the collection of additional data using other tools, such as a survey of the behaviours and tasks of a wider sample of rehabilitation workers, could strengthen data reliability. Experts perceived findings of the competency analysis to be valuable for expanding the understanding of rehabilitation, shedding light on task allocation and deployment of the existing rehabilitation workforce, and advocating for the rehabilitation workforce to be strengthened, especially in relation to those occupations which may not be recognised or valued as rehabilitation workers. Although it was not possible to fully explore the impact of competency analysis data on rehabilitation workforce planning and development in this study, experts suggested that its availability would likely foster greater cooperation among occupations, which has been missing at the policy and planning level to date. It further demonstrates what competency data should be collected and reported, and provides richer information to guide decisions. Conclusions Competency analysis complements traditional labour market analysis and workload estimates, adding depth to the understanding of how members of the workforce perform and perceive themselves, and how deficiencies in the workforce impact on the provision of care to specific population groups.

Objective The objective of this paper is to establish whether existing eye care competency frameworks (ECCF) are fit for purpose, and set out a comprehensive ECCF that better meets the needs of the eye care workforce and broader population.Methods and analysis We carried out a two-stage process. The first was to conduct a desk review of existing frameworks and models relevant to eye care competencies. The second was to conduct a broad stakeholder consultation of global eye care experts to affirm the gaps found in the first stage, and to inform the development of a comprehensive ECCF.Results We reviewed 52 competency frameworks, competency standards and models related to eye care (including 11 from the UK) and found that there were three types of gaps, such as: (1) narrow in focus on specific occupational groups; (2) limitations in the competencies expected from an eye care worker and (3) limitations in regional focus, such that they could not easily be applied in a global context.Having affirmed these gaps during the stakeholder consultation stage, we developed a more comprehensive ECCF structure, which composed of six domains: practice, professionalism, learning and development, management and leadership, community and advocacy, and evidence. This broader structure seeks to address the gaps found in the desk review.Conclusion The review showed that there was a need to develop a comprehensive ECCF that can be easily contextualised, encapsulate the roles of the diverse eye care workforce, and be a tool for eye care workforce planning and development to meet the needs of a global population.