Service Readiness For Noncommunicable Diseases Was Low In Five Countries In 2013-15.

The growing burden of noncommunicable diseases (NCDs) may pose challenges for resource-limited health systems. This study used standardized, nationally representative data from Service Provision Assessments conducted in 2013-15 and the Service Availability and Readiness Assessment methodology to examine NCD service availability and readiness in Bangladesh, Haiti, Malawi, Nepal, and Tanzania. Both service availability and readiness were found to be very low: Very few facilities were fully "ready" to provide any one NCD service. Shortages of trained health workers and essential medicines were critical limitations to readiness. Rural and free facilities had lower availability and readiness, which may present access barriers. Policy makers should draw on decades of experience with global health initiatives to close these service gaps through the training of health workers on NCD screening and treatment, engaging the private sector on NCDs, and ensuring access to NCD medicines. Such efforts must be attentive to distributional equity and the multiple dimensions of care quality.

The Economic Consequences Of Mortality Amenable To High-Quality Health Care In Low- And Middle-Income Countries.

We estimated deaths amenable to high-quality health care globally and then modeled the macroeconomic impact in low- and middle-income countries using two macroeconomic perspectives: a value-of-lost-output approach to project gross domestic product (GDP) losses annually for the period 2015-30, and a value-of-lost-welfare approach to estimate the present value of total economic welfare losses in 2015. We estimated that eight million amenable deaths occurred in 2015, 96 percent of them in low- and middle-income countries. The value of lost output resulted in a projected cumulative loss of $11.2 trillion in these countries during 2015-30, with a potential economic output loss of up to 2.6 percent of GDP in low-income countries by 2030, compared to 0.9 percent in upper-middle-income countries. The value-of-lost-welfare approach estimated welfare losses of $6.0 trillion in 2015. Inadequate access to high-quality health care results in significant mortality and imposes a macroeconomic burden that is inequitably distributed, with the largest relative burden falling on low-income countries. Given that these deaths are unnecessary and the projected GDP losses are avoidable, there is a strong ethical and economic case for promoting high-quality health care as an essential component of universal health coverage.

The Equity Impact Vaccines May Have On Averting Deaths And Medical Impoverishment In Developing Countries.

With social policies increasingly directed toward enhancing equity through health programs, it is important that methods for estimating the health and economic benefits of these programs by subpopulation be developed, to assess both equity concerns and the programs' total impact. We estimated the differential health impact (measured as the number of deaths averted) and household economic impact (measured as the number of cases of medical impoverishment averted) of ten antigens and their corresponding vaccines across income quintiles for forty-one low- and middle-income countries. Our analysis indicated that benefits across these vaccines would accrue predominantly in the lowest income quintiles. Policy makers should be informed about the large health and economic distributional impact that vaccines could have, and they should view vaccination policies as potentially important channels for improving health equity. Our results provide insight into the distribution of vaccine-preventable diseases and the health benefits associated with their prevention.

Innovative Product Development Partnership Reduced Neonatal Mortality In Nepal Through Improved Umbilical Cord Care.

Approximately 40 percent of all newborn deaths in Nepal are attributable to neonatal infections. A randomized controlled trial conducted in Nepal in the period 2002-05 on the application of a solution of the disinfectant chlorhexidine to umbilical cord stumps of newborns showed a reduced risk of infections and death. In response to these results, the Government of Nepal and various partners mobilized to deliver this simple, low-cost intervention on a national scale. We describe the design, development, and maturation of a partnership among the government, technical assistance agencies, and a local pharmaceutical company to create a suitable, commercially available gel product to reduce newborn infections. Essential contributors to the partnership's effectiveness included having a for-profit pharmaceutical company as a fully engaged partner; having responsive, flexible relationships among the partners that evolved over time; and paying attention to competition within the private sector. A less formalized arrangement among partners allowed them to build trust in each other over time. Government stewardship of the program throughout the scale-up process ensured that policy and systems integration were aligned as the program matured.

Measuring The Impact Of Cash Transfers And Behavioral 'Nudges' On Maternity Care In Nairobi, Kenya.

Many patients in low-income countries express preferences for high-quality health care but often end up with low-quality providers. We conducted a randomized controlled trial with pregnant women in Nairobi, Kenya, to analyze whether cash transfers, enhanced with behavioral "nudges," can help women deliver in facilities that are consistent with their preferences and are of higher quality. We tested two interventions. The first was a labeled cash transfer (LCT), which explained that the cash was to help women deliver where they wanted. The second was a cash transfer that combined labeling and a commitment by the recipient to deliver in a prespecified desired facility as a condition of receiving the final payment (L-CCT). The L-CCT improved patient-perceived quality of interpersonal care but not perceived technical quality of care. It also increased women's likelihood of delivering in facilities that met standards for routine and emergency newborn care but not the likelihood of delivering in facilities that met standards for obstetric care. The LCT had fewer measured benefits. Women preferred facilities with high technical and interpersonal care quality, but these quality measures were often negatively correlated within facilities. Even with cash transfers, many women still used poor-quality facilities. A larger study is warranted to determine whether the L-CCT can improve maternal and newborn outcomes.

Microfinance Institutions' Successful Delivery Of Micronutrient Powders: A Randomized Trial In Rural Haiti.

Globally, two-thirds of child deaths could be prevented by increased provision of health interventions such as vaccines, micronutrient supplements, and water purification tablets. We report the results from a randomized controlled trial in Haiti during 2012 that tested whether microfinance institutions-which reach 200 million households worldwide-can effectively deliver health products. These institutions provide loans to underserved entrepreneurs, primarily poor women in rural areas. In the intervention group, micronutrient powders to improve the nutrition of young children were distributed at regularly occurring microfinance meetings by a trained borrower. In both the control and the intervention groups, nurses led seminars on nutrition and extended breastfeeding during microfinance meetings. At three-month follow-up, the mean difference in hemoglobin concentration between children in the intervention group and those in the control group was 0.28 grams per deciliter (g/dL)-with a subsample of younger children (under two years of age) showing greater relative improvement (0.46 g/dL)-and the odds ratio for children in the intervention group meeting the diagnostic criteria for anemia was 0.64. The results are similar to those of previous studies that evaluated micronutrient powder distribution through dedicated health institutions. Our findings suggest that microfinance institutions are a promising platform for the large-scale delivery of health products in low-income countries.

Accountable Care Reforms Improve Women's And Children's Health In Nepal.

Over the past decade the Ministry of Health of Nepal and the nonprofit Possible have partnered to deliver primary and secondary health care via a public-private partnership. We applied an accountable care framework that we previously developed to describe the delivery of their integrated reproductive, maternal, newborn, and child health services in the Achham district in rural Nepal. In a prospective pre-post study, examining pregnancies at baseline and 541 pregnancies in follow-up over the course of eighteen months, we found an improvement in population-level indicators linked to reducing maternal and infant mortality: receipt of four antenatal care visits (83 percent to 90 percent), institutional birth rate (81 percent to 93 percent), and the prevalence of postpartum contraception (19 percent to 47 percent). The intervention cost $3.40 per capita (at the population level) and $185 total per pregnant woman who received services. This study provides new analysis and evidence on the implementation of innovative care and financing models in resource-limited settings.

Lower-Income Countries That Face The Most Rapid Shift In Noncommunicable Disease Burden Are Also The Least Prepared.

Demographic and epidemiological changes are shifting the disease burden from communicable to noncommunicable diseases in lower-income countries. Within a generation, the share of disease burden attributed to noncommunicable diseases in some poor countries will exceed 80 percent, rivaling that of rich countries, but this burden is likely to affect much younger people in poorer countries. The health systems of lower-income countries are unprepared for this change. We examined the shift to noncommunicable diseases and estimated preparedness for the shift by ranking 172 nations using a health system capacity index for noncommunicable disease. We project that the countries with the greatest increases in the share of disease burden attributable to noncommunicable disease over the next twenty-five years will also be the least prepared for the change, as they ranked low on our capacity index and are expected to have the smallest increases in national health spending. National governments and donors must invest more in preparing the health systems of lower-income countries for the dramatic shift to noncommunicable diseases and in reducing modifiable noncommunicable disease risks.

A Voucher System To Speed Review Could Promote A New Generation Of Insecticides To Fight Vector-Borne Diseases.

Many in the scientific community are concerned about the potential increase in prevalence of insect-borne diseases such as Chagas disease, Chikungunya, dengue fever, malaria, and Zika in the United States and around the world. Beyond vaccines and drugs to prevent and treat these diseases, a comprehensive approach to fighting these diseases should include control of disease-carrying vectors, such as mosquitoes. Vector-control methods, such as using insecticides to treat bed nets and spray the walls of homes, have prevented millions of deaths from malaria. However, mosquitoes are becoming resistant to insecticides, and no new class of insecticides for vector control has been introduced in decades. We recommend the creation of a new type of incentive for the development and commercialization of safe new insecticides: a Vector Expedited Review Voucher, to be awarded to a sponsor that introduces a novel insecticide for public health use. The voucher could be redeemed to expedite registration of a second, more profitable, product by the US Environmental Protection Agency.

Mongolia's Public Spending On Noncommunicable Diseases Is Similar To The Spending Of Higher-Income Countries.

Although there is increased recognition of the global challenge posed by noncommunicable diseases (NCDs), translating that awareness into resources for action requires better data than typically available in low- and middle-income countries. One middle-income country that does have good-quality information is Mongolia. Using detailed administrative data from Mongolia and supplementary survey-based information, we estimated public spending on four NCDs in Mongolia and reached four main conclusions. First, Mongolia's public spending patterns on NCDs are similar to NCD spending observed in countries with much higher per capita incomes. Second, public spending for NCDs is low relative to the NCD disease burden in Mongolia. Third, public-sector NCD spending is dominated by inpatient care and hospital-based specialist outpatient services, which suggests inefficiency in resource use. Finally, while public spending on cardiovascular disease is evenly distributed across regions, for cancers it is heavily concentrated in the nation's capital.

Industry-Led Access-To-Medicines Initiatives In Low- And Middle-Income Countries: Strategies And Evidence.

Global biopharmaceutical companies are increasingly establishing access-to-medicines (AtM) initiatives in low- and middle-income countries. We reviewed the initiatives of twenty-one research-based global biopharmaceutical companies to assess their strategies for improving access and the quality of evidence on the impact of their initiatives. The number of operating initiatives increased from 17 in 2000 to 102 in 2015. Of the 120 different AtM initiatives identified, 48 percent used a medicine donation strategy, and 44 percent used a price reduction strategy. While companies have frequently claimed that their initiatives have had positive impacts, we found published evaluations for only seven initiatives, and nearly all of the evaluations were of low (62 percent) or very low (32 percent) quality. It is clear that the biopharmaceutical industry has increased its commitment to improving access to medicines in low- and middle-income countries. However, companies should do more to generate high-quality evidence on their initiatives, and the global health community should do more to assist the developing of evidence about the initiatives.

Trends In State-Level Child Mortality, Maternal Mortality, And Fertility Rates In India.

Trends in child mortality, maternal mortality, and fertility in India reveal wide variation across states. As a whole, India performs worse than many other low- and middle-income countries, although its rates of improvement have recently increased. Differences in health systems and adopted policies may account for some of the variation across Indian states.

Ambulance Service Associated With Reduced Probabilities Of Neonatal And Infant Mortality In Two Indian States.

India had no large-scale, centralized emergency medical system or ambulance service until 2005. Since then, the GVK Emergency Management and Research Institute (GVK EMRI) has emerged as India's largest ambulance service provider, covering more than 630 million people. This study provides the first quantitative evidence of GVK EMRI's early impact on population-level infant and maternal health outcomes in Andhra Pradesh and Gujarat, two Indian states with a combined population of about 145 million people. We found that GVK EMRI coverage is associated with reductions in the probability of neonatal and infant mortality as well as delivery complications (statewide in Andhra Pradesh and in high-mortality districts in Gujarat). However, we found little change in the probability of institutional delivery or skilled birth attendance. Taken together, our findings suggest that population-level health gains were achieved through improvements in the quality (rather than quantity) of maternal and neonatal health services-an interpretation consistent with qualitative reports. More research on this topic is needed.

A Sustainable Model For Delivering High-Quality, Efficient Cataract Surgery In Southern India.

Cataracts are a leading cause of reversible blindness in India, where millions of people can be effectively treated for this condition with surgery. The Aravind Eye Care System in southern India developed an efficient system for delivering high-quality and low-cost cataract surgery. We provide a detailed accounting of costs of cataract surgery at the system and a cost-utility analysis. Total costs per operation were US$120, or $195 per quality-adjusted life-year gained. Using these data and population-based estimates of cataract prevalence, we calculate that eliminating cataract-related blindness and low vision in India would cost $2.6 billion and would yield a net societal benefit of $13.5 billion. Factors contributing to the highly cost-effective care at the Aravind Eye Care System include the domestic manufacturing of supplies, the use of a specialized workforce and standardized protocols, and the presence of few regulatory hurdles. Lessons learned from the system can help improve the delivery of cataract surgery and other ambulatory care surgeries in India and abroad.

India's Largest Hospital Insurance Program Faces Challenges In Using Claims Data To Measure Quality.

The routine data generated by India's universal coverage programs offer an important opportunity to evaluate and track the quality of health care systematically and on a large scale. We examined the potential and challenges of measuring the quality of hospital care through claims data from India's hospital insurance program for the poor, Rashtriya Swasthya Bima Yojana (RSBY). Using data from one district in India, we illustrate how these data already provide useful insights and show that simple efforts to enhance data quality and an effort to expand the data captured could facilitate RSBY's ability to track quality of care. The data collected by RSBY has significant potential to characterize and uncover the provision of low-quality care and help inform much-needed efforts to raise the quality of hospital care.