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IntroductionThe current financing of public-sector district hospitals in India relies on historical budget allocations rather than actual utilization or healthcare needs. We utilized empirical data on healthcare delivery costs to develop the financing framework for these hospitals using a blended payment approach.MethodsThe primary data on cost of delivering services in 27 district hospitals across nine states of India was analysed along with indicators influencing the demand and supply of health services. Payment for outpatient, inpatient, and indirect services was assessed using the risk adjusted global budget, case-based bundled payment, and per-bed-global budget, respectively. Risk adjustment weights were computed by regressing the cost of outpatient care with demand and supply side factors which are likely to influence the utilization or the prices. Budget impact analysis was conducted to assess the fiscal implications of this payment approach, accounting for current care standards and two scenarios: upgrading district hospitals to Indian Public Health Standards (IPHS) or medical colleges.ResultsThe average annual budget for a district hospital in India is estimated at ₹326 million (US$3.35 million), ranging from ₹66 million to ₹2.57 billion (US$0.8–31.13 million). Inpatient care comprises the largest portion (78%) of the budget. Upgrading to IPHS-compliant secondary hospitals or medical colleges would increase average budgets by 131 and 91.5%, respectively.ConclusionImplementing a blended payment approach would align funding with healthcare needs, enhance provider performance, and support ongoing financing reforms aimed at strategic purchasing and universal health coverage.

BackgroundLife expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available.New research networkIn order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens.ConclusionFurther research using this framework has considerable potential to advance effective policies to advance health and equity.

PROBLEM: The lack of skilled service providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved. APPROACH: The National Rural Health Mission, launched by the Government of India in 2005, promoted various state and national initiatives to address this issue. Under India's federal constitution, the states are responsible for implementing the health system with financial support from the national government. LOCAL SETTING: The availability of doctors and nurses is limited by a lack of training colleges in states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Before 2005, the most common strategy was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programmes. RELEVANT CHANGES: Initiatives under the National Rural Health Mission include an increase in sanctioned posts for public health facilities, incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82 343 skilled health workers to the public health workforce. LESSONS LEARNT: The problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programmes have shown promising results. Most of these strategies are too recent for outcome evaluation, although this would help optimize and develop an ideal mix of strategies for different contexts.

Our paper examines the political considerations in the intersectoral action that was evident during the SAR-COV-2 virus (COVID-19) pandemic through case studies of political and institutional responses in 16 nations (Australia, Belgium, Brazil, Ethiopia, India, New Zealand, Nigeria, Peru, South Africa, South Korea, Spain, Taiwan, Thailand, Vietnam, UK, and USA). Our qualitative case study approach involved an iterative process of data gathering and interpretation through the three Is (institutions, ideas and interests) lens, which we used to shape our understanding of political and intersectoral factors affecting pandemic responses. The institutional factors examined were: national economic and political context; influence of the global economic order; structural inequities; and public health structures and legislation, including intersectoral action. The ideas explored were: orientation of governments; political actors' views on science; willingness to challenge neoliberal policies; previous pandemic experiences. We examined the interests of political leaders and civil society and the extent of public trust. We derived five elements that predict effective and equity-sensitive political responses to a pandemic. Firstly, effective responses have to be intersectoral and led from the head of government with technical support from health agencies. Secondly, we found that political leaders' willingness to accept science, communicate empathetically and avoid 'othering' population groups was vital. The lack of political will was found in those countries stressing individualistic values. Thirdly, a supportive civil society which questions governments about excessive infringement of human rights without adopting populist anti-science views, and is free to express opposition to the government encourages effective political action in the interests of the population. Fourthly, citizen trust is vital in times of uncertainty and fear. Fifthly, evidence of consideration is needed regarding when people's health must be prioritized over the needs of the economy. All these factors are unlikely to be present in any one country. Recognizing the political aspects of pandemic preparedness is vital for effective responses to future pandemics and while intersectoral action is vital, it is not enough in isolation to improve pandemic outcomes., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)