Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal.

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal's commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.

Understanding perceptions of global healthcare experiences on provider values and practices in the USA: a qualitative study among global health physicians and program directors.

OBJECTIVES: The study aimed to qualitatively examine the perspectives of US-based physicians and academic global health programme leaders on how global health work shapes their viewpoints, values and healthcare practices back in the USA. DESIGN: A prospective, qualitative exploratory study that employed online questionnaires and open-ended, semi-structured interviews with two participant groups: (1) global health physicians and (2) global health programme leaders affiliated with USA-based academic medical centres. Open coding procedures and thematic content analysis were used to analyse data and derive themes for discussion. PARTICIPANTS: 159 global health physicians and global health programme leaders at 25 academic medical institutions were invited via email to take a survey and participate in a follow-up interview. Twelve participants completed online questionnaires (7.5% response rate) and eight participants (four survey participants and four additionally recruited participants) participated in in-depth, in-person or phone semi-structured interviews. RESULTS: Five themes emerged that highlight how global health physicians and academic global health programme leaders perceive global health work abroad in shaping USA-based medical practices: (1) a sense of improved patient rapport, particularly with low-income, refugee and immigrant patients, and improved and more engaged patient care; (2) reduced spending on healthcare services; (3) greater awareness of the social determinants of health; (4) deeper understanding of the USA's healthcare system compared with systems in other countries; and (5) a reinforcement of values that initially motivated physicians to pursue work in global health. CONCLUSIONS: A majority of participating global health physicians and programme leaders believed that international engagements improved patient care back in the USA. Participant responses relating to the five themes were contextualised by highlighting factors that simultaneously impinge on their ability to provide improved patient care, such as the social determinants of health, and the challenges of changing USA healthcare policy.

Competencies for Global Mental Health: Developing Training Objectives for a Post-Graduate Fellowship for Psychiatrists.

BACKGROUND: Despite an increase in psychiatry trainees' interest in global mental health (GMH), there is a lack of relevant training competencies developed using educational frameworks that incorporate viewpoints from high- and low-income countries. Objective: The aim of this study was to determine competencies for a two-year post-graduate GMH fellowship for psychiatrists utilizing Kern's six-step process as a theoretical framework for curriculum development. Methods: We conducted a targeted needs assessment via key informant interviews with a purposive sample of stakeholders (n = 19), including psychiatry trainees, generalist clinicians, medical directors, psychiatrists, researchers, and GMH educators from high- and low-resource settings in the United States and abroad. We analyzed data using a template method of thematic analysis. Findings: We tabulated learning objectives across 20 domains. Broadly, clinical objectives focused on providing supervision for short-term, evidence-based psychotherapies and on identifying red flags and avoiding harmful medication use among vulnerable populations such as children and the elderly. Non-clinical objectives focused on social determinants of health, education, and clinical supervision as part of capacity-building for non-specialists, engagement in a systems-wide project to improve care, and ethical and equitable partnerships that involve reciprocal and bidirectional education. Several competencies were also relevant for global health work in general. Conclusions: A theory-informed framework for curriculum development and a diverse set of key informants can provide educational objectives that meet the priorities of the trainees and the clinical sites in both low- and high-income settings. Limitations of this study include a small sample size and a focus on clinical needs of specific sites, both of which may affect generalizability. Given the focus on training specialists (psychiatrists), the low-resource sites highlighted the importance of educating and supervising their permanent, generalist clinicians, rather than providing direct, independent patient care.

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal.

BACKGROUND: Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. METHODS: We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. RESULTS: We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. CONCLUSION: The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Power, potential, and pitfalls in global health academic partnerships: review and reflections on an approach in Nepal.

BACKGROUND: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe. OBJECTIVES: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings. METHODS: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework. RESULTS: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships. CONCLUSIONS: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians.

Collaborative Care for Mental Health in Low- and Middle-Income Countries: A WHO Health Systems Framework Assessment of Three Programs.

The collaborative care model is an evidence-based intervention for behavioral and other chronic conditions that has the potential to address the large burden of mental illness globally. Using the World Health Organization Health Systems Framework, the authors present challenges in implementing this model in low- and middle-income countries (LMICs) and discuss strategies to address these challenges based on experiences with three large-scale programs: an implementation research study in a district-level government hospital in rural Nepal, one clinical trial in 50 primary health centers in rural India, and one study in four diabetes clinics in India. Several strategies can be utilized to address implementation challenges and enhance scalability in LMICs, including mobilizing community resources, engaging in advocacy, and strengthening the overall health care delivery system.

Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal.

BACKGROUND: Mental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation. PARTNERSHIPS NETWORK: We describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community. CONCLUSIONS: We propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

The Mental Health Education Gap among Primary Care Providers in Rural Nepal.

OBJECTIVE: In low- and middle-income countries, the majority of individuals with mental illness go untreated largely because of a severe shortage of mental health professionals. Global initiatives to close the mental health treatment gap focus on primary care providers delivering this care. For this to be effective, primary care providers require the skills to assess, diagnose, and treat patients with mental illness. METHODS: To assess primary care providers' training and experience in caring for mental health patients, the authors conducted five focus groups at three isolated district hospitals in rural Nepal where there was no access to mental health professionals. RESULTS: Primary care providers reported limited training, lack of knowledge and skills, and discomfort in delivering mental health care. CONCLUSION: To address the mental health education gap, primary care providers in Nepal, and perhaps other low- and middle-income countries, require more training during both undergraduate and graduate medical education.

Crossing the quality chasm in resource-limited settings.

Over the last decade, extensive scientific and policy innovations have begun to reduce the "quality chasm"--the gulf between best practices and actual implementation that exists in resource-rich medical settings. While limited data exist, this chasm is likely to be equally acute and deadly in resource-limited areas. While health systems have begun to be scaled up in impoverished areas, scale-up is just the foundation necessary to deliver effective healthcare to the poor. This perspective piece describes a vision for a global quality improvement movement in resource-limited areas. The following action items are a first step toward achieving this vision: 1) revise global health investment mechanisms to value quality; 2) enhance human resources for improving health systems quality; 3) scale up data capacity; 4) deepen community accountability and engagement initiatives; 5) implement evidence-based quality improvement programs; 6) develop an implementation science research agenda.