Comprehensive Nutrient Gap Assessment (CONGA): A method for identifying the public health significance of nutrient gaps.

Identifying dietary nutrient gaps and interpreting their public health significance are essential for improving poor diets and reducing malnutrition. Evidence indicative of the burden of nutrient deficiencies and inadequate nutrient intake or availability exists in many countries yet is often misinterpreted or underused in decision-making. Clear guidance is lacking on how to synthesize and interpret the relevant evidence, which comes in many forms. To fill this methodological gap, an approach called Comprehensive Nutrient Gap Assessment was created to enable use of existing evidence to assess the public health significance of nutrient gaps and identify evidence gaps. Comprehensive Nutrient Gap Assessment requires ≥ 2 experts in nutritional assessment but does not require primary data collection or secondary quantitative data analysis. It can be implemented relatively quickly with low costs, for specific countries and subnational regions, and updated on the basis of new data with minimal effort. The findings from a Comprehensive Nutrient Gap Assessment are easily interpretable by nontechnical decision makers yet include clear justification for technical audiences.

Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-Food Consumption: A Meta-Analysis of Global School-Based Student Health Surveys.

BACKGROUND: Adolescence presents an opportunity to influence diet, which impacts present and future health outcomes, yet adolescent diets globally are poorly understood. OBJECTIVE: We generate evidence on adolescent diets globally and explore patterns and trends by subpopulation. METHODS: We estimated mean frequency of consumption and prevalence of less-than-daily fruit and vegetable consumption, at-least-daily carbonated beverage consumption, and at-least-weekly fast-food consumption among school-going adolescents aged primarily 12 to 17 years from the Global School-based Student Health Surveys in Africa, Asia, Oceania, and Latin America between 2008 and 2015. Random-effects meta-analysis was used to pool estimates globally and by subgroup. RESULTS: On average, adolescents consumed fruit 1.43 (95% confidence interval [CI] 1.26-1.60) times per day, vegetables 1.75 (1.58-1.92) times per day, carbonated soft drinks 0.99 (0.77-1.22) times per day, and fast food 1.05 (0.78-1.32) times per week. Overall, 34.5% (95% CI 29.4-39.7) consumed fruit less than once per day, 20.6% (15.8-25.9) consumed vegetables less than once per day, 42.8% (35.2-50.7) drank carbonated soft drinks at least once per day, and 46.1% (38.6-53.7) consumed fast food at least once per week. Mean daily frequency of fruit consumption was particularly low in South and East Asia (1.30 [1.02-1.58]); carbonated soft drink consumption high in Latin America (1.54 [1.31-1.78]), high-income countries (1.66 [1.29-2.03]), and modern food system typologies (1.44 [0.75-2.12]); and mean weekly fast food consumption high in mixed food system typologies (1.29 [0.88-1.71]). CONCLUSIONS: School-going adolescents infrequently consume fruits and vegetables and frequently consume carbonated soft drinks, but there is wide variability by subpopulation.

An egg for everyone: Pathways to universal access to one of nature's most nutritious foods.

Eggs are a highly nutritious food but have been shown to be infrequently consumed in many low-income countries, especially by women and children. We collate country-level data on egg production, availability, consumption, prices, industry structure, and contextual trends and use these to estimate current patterns and likely future outcomes under four alternative scenarios. These scenarios are as follows: incremental change based on expected economic growth and urbanisation (the base scenario); enhanced productivity of independent small producers; aggregated production in egg hubs; and the accelerated spread of large-scale intensive production. All scenarios are modelled out to 2030 using a mix of regression and deterministic models. We find that children's consumption of eggs is highly correlated with national availability, and both are a function of egg prices. Eggs are unavailable, expensive, and infrequently consumed by children in much of South Asia and sub-Saharan Africa. The base scenario results in modest increases in production in low-income regions. Focusing efforts on independent small producers can only boost rural consumption in a handful of countries where poultry ownership is unusually high and would be expensive and logistically challenging to scale. Aggregation of production, with minimum flock sizes of 5,000 layers per farm, is a more promising pathway to increasing availability in rural areas. To meet the needs of urban populations, large-scale intensive production is needed. Intensive production brings down prices significantly, allowing many more poor households to access and consume eggs. Recent experience in countries such as Thailand confirms that this is both feasible and impactful.

Care-seeking and appropriate treatment for childhood acute respiratory illness: an analysis of Demographic and Health Survey and Multiple Indicators Cluster Survey datasets for high-mortality countries.

BACKGROUND: Acute lower respiratory illness (ALRI) is a major global cause of morbidity and mortality among children under 5. Antibiotic treatment for ALRI is inexpensive and decreases case fatality, but care-seeking patterns and appropriate treatment vary widely across countries. This study sought to examine patterns of appropriate treatment and estimate the burden of cases of untreated ALRI in high mortality countries. METHODS: This study used cross-sectional survey data from the Phase 5/Phase 6 DHS and MIC3/MICS4 for 39 countries. We analyzed care-seeking patterns and antibiotic treatment based on country-level trends, and estimated the burden of untreated cases using country-level predictors in a general linear model. RESULTS: According to this analysis, over 66 million children were not treated with antibiotics for ALRI in 2010. Overall, African countries had a lower proportion of mothers who sought care for a recent episode of ALRI (41% to 86%) relative to Asian countries (75% to 87%). Seeking any care for ALRI was inversely related to seeking public sector care. Treatment with antibiotics ranged from 8% in Nepal to 87% in Jordan, and was significantly associated with urban residence. CONCLUSIONS: Untreated ALRI remains a substantial problem in high mortality countries. In Asia, the large population numbers lead to a high burden of children with untreated ALRI. In Africa, care-seeking behaviors and access to care issues may lead to missed opportunities to treat children with antibiotics.

Scaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low- and high-performing countries.

AIM: This paper aims to identify factors that systematically predict why some countries that have tried to scale up oral rehydration solution (ORS) have succeeded, and others have not. METHODS: We examined ORS coverage over time, across countries, and through case studies. We conducted expert interviews and literature and data searches to better understand the history of ORS scale-up efforts and why they failed or succeeded in nine countries. We used qualitative, pairwise (or three-country) comparisons of geographically or otherwise similar countries that had different outcomes in terms of ORS scale-up. An algorithm was developed which scored country performance across key supply, demand and financing activities to quantitatively assess the scale-up efforts in each country. RESULTS: The vast majority of countries have neither particularly low nor encouragingly high ORS use rates. We observed three clearly identifiable contrasts between countries that achieved and sustained high ORS coverage and those that did not. Key partners across sectors have critical roles to play to effectively address supply- and demand-side barriers. Efforts must synchronize demand generation, private provider outreach and public sector work. Many donor funds are either suspended or redirected in the event of political instability, exacerbating the health challenges faced by countries in these contexts. We found little information on the cost of scale-up efforts. CONCLUSIONS: We identified a number of characteristics of successful ORS scale-up programs, including involvement of a broad range of key players, addressing supply and demand generation together, and working with both public and private sectors. Dedicated efforts are needed to launch and sustain success, including monitoring and evaluation plans to track program costs and impacts. These case studies were designed to inform programmatic decision-making; thus, rigorous academic methods to qualitatively and quantitatively evaluate country ORS scale-up programs might yield additional, critical insights and confirm our conclusions.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.

BACKGROUND: The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010. METHODS: We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies. FINDINGS: We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3-13·9 million) episodes of severe and 3·0 million (2·1-4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265,000 (95% CI 160,000-450,000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals. INTERPRETATION: Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities. FUNDING: WHO.

Multi-country analysis of the effects of diarrhoea on childhood stunting.

Diarrhoea is an important cause of death and illness among children in developing countries; however, it remains controversial as to whether diarrhoea leads to stunting. We conducted a pooled analysis of nine studies that collected daily diarrhoea morbidity and longitudinal anthropometry to determine the effects of the longitudinal history of diarrhoea prior to 24 months on stunting at age 24 months. Data covered a 20-year period and five countries. We used logistic regression to model the effect of diarrhoea on stunting. The prevalence of stunting at age 24 months varied by study (range 21-90%), as did the longitudinal history of diarrhoea prior to 24 months (incidence range 3.6-13.4 episodes per child-year, prevalence range 2.4-16.3%). The effect of diarrhoea on stunting, however, was similar across studies. The odds of stunting at age 24 months increased multiplicatively with each diarrhoeal episode and with each day of diarrhoea before 24 months (all P < 0.001). The adjusted odds of stunting increased by 1.13 for every five episodes (95% CI 1.07-1.19), and by 1.16 for every 5% unit increase in longitudinal prevalence (95% CI 1.07-1.25). In this assembled sample of 24-month-old children, the proportion of stunting attributed to >or=5 diarrhoeal episodes before 24 months was 25% (95% CI 8-38%) and that attributed to being ill with diarrhoea for >or=2% of the time before 24 months was 18% (95% CI 1-31%). These observations are consistent with the hypothesis that a higher cumulative burden of diarrhoea increases the risk of stunting.

What works? Interventions for maternal and child undernutrition and survival.

We reviewed interventions that affect maternal and child undernutrition and nutrition-related outcomes. These interventions included promotion of breastfeeding; strategies to promote complementary feeding, with or without provision of food supplements; micronutrient interventions; general supportive strategies to improve family and community nutrition; and reduction of disease burden (promotion of handwashing and strategies to reduce the burden of malaria in pregnancy). We showed that although strategies for breastfeeding promotion have a large effect on survival, their effect on stunting is small. In populations with sufficient food, education about complementary feeding increased height-for-age Z score by 0.25 (95% CI 0.01-0.49), whereas provision of food supplements (with or without education) in populations with insufficient food increased the height-for-age Z score by 0.41 (0.05-0.76). Management of severe acute malnutrition according to WHO guidelines reduced the case-fatality rate by 55% (risk ratio 0.45, 0.32-0.62), and recent studies suggest that newer commodities, such as ready-to-use therapeutic foods, can be used to manage severe acute malnutrition in community settings. Effective micronutrient interventions for pregnant women included supplementation with iron folate (which increased haemoglobin at term by 12 g/L, 2.93-21.07) and micronutrients (which reduced the risk of low birthweight at term by 16% (relative risk 0.84, 0.74-0.95). Recommended micronutrient interventions for children included strategies for supplementation of vitamin A (in the neonatal period and late infancy), preventive zinc supplements, iron supplements for children in areas where malaria is not endemic, and universal promotion of iodised salt. We used a cohort model to assess the potential effect of these interventions on mothers and children in the 36 countries that have 90% of children with stunted linear growth. The model showed that existing interventions that were designed to improve nutrition and prevent related disease could reduce stunting at 36 months by 36%; mortality between birth and 36 months by about 25%; and disability-adjusted life-years associated with stunting, severe wasting, intrauterine growth restriction, and micronutrient deficiencies by about 25%. To eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women's empowerment.

Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress?

Many transnational organisations work to support efforts to eliminate maternal and child undernutrition in high-burden countries. Financial, intellectual, and personal linkages bind these organisations loosely together as components of an international nutrition system. In this paper, we argue that such a system should deliver in four functional areas: stewardship, mobilisation of financial resources, direct provision of nutrition services at times of natural disaster or conflict, and human and institutional resource strengthening. We review quantitative and qualitative data from various sources to assess the performance of the system in each of these areas, and find substantial shortcomings. Fragmentation, lack of an evidence base for prioritised action, institutional inertia, and failure to join up with promising developments in parallel sectors are recurrent themes. Many of these weaknesses can be attributed to systemic problems affecting most organisations working in the field; these are analysed using a problem tree approach. We also make recommendations to overcome some of the most important problems, and we propose five priority actions for the development of a new international architecture.

Equitable utilisation of Indian community based health insurance scheme among its rural membership: cluster randomised controlled trial.

OBJECTIVE: To evaluate alternative strategies for improving the uptake of benefits of a community based health insurance scheme by its poorest members. DESIGN: Prospective cluster randomised controlled trial. SETTING: Self Employed Women's Association (SEWA) community based health insurance scheme in rural India. Participants 713 claimants at baseline (2003) and 1440 claimants two years later among scheme members in 16 rural sub-districts. INTERVENTIONS: After sales service with supportive supervision, prospective reimbursement, both packages, and neither package, randomised by sub-district. MAIN OUTCOME MEASURES: The primary outcome was socioeconomic status of claimants relative to members living in the same sub-district. Secondary outcomes were enrolment rates in SEWA Insurance, mean socioeconomic status of the insured population relative to the general rural population, and rate of claim submission. RESULTS: Between 2003 and 2005, the mean socioeconomic status of SEWA Insurance members (relative to the rural population of Gujarat) increased significantly. Rates of claims also increased significantly, on average by 21.6 per 1000 members (P<0.001). However, differences between the intervention groups and the standard scheme were not significant. No systematic effect of time or interventions on the socioeconomic status of claimants relative to members in the same sub-district was found. CONCLUSIONS: Neither intervention was sufficient to ensure that the poorer members in each sub-district were able to enjoy the greater share of the scheme benefits. Claim submission increased as a result of interventions that seem to have strengthened awareness of and trust in a community based health insurance scheme. Trial registration Clinical trials NCT00421629.

Measuring improved targeting of health interventions to the poor in the context of a community-randomised trial in rural India.

In spite of growing interest in socioeconomic differentials in health outcomes and access to health services, little has been written about methodologies for assessing the impact of equity-enhancing policies or programs. This paper describes three methodological challenges involved in designing a randomised trial with an equity outcome, and how these were met in a trial of alternative strategies to improving the uptake of benefits of a health insurance scheme among its poorest members. The Vimo SEWA trial is nested within a community-based insurance scheme in rural India. While conducting this trial, three methodological problems were encountered: (i) measuring poverty (or "wealth", or "socioeconomic status") (ii) assessing beneficiaries against an appropriate reference standard population and (iii) settling on an appropriate equity measure as an outcome indicator. These problems are likely to arise in any policy or program assessment that has an equity outcome. In the Vimo SEWA trial, the socioeconomic status of beneficiaries (claimants) is assessed relative to that of all scheme members living in same sub-district by applying a rapid assessment questionnaire--which reduces to an integrated index of socioeconomic status--to both a random sample of members in each sub-district, and to all claimants. The results are used to estimate the full distribution of socioeconomic status of members in each sub-district, with each member given a rank score between 0 and 100. Interpolation is used to estimate the rank scores of claimants relative to the membership base. The primary outcome measure for the trial is the mean socioeconomic rank score of claimants. In developing country settings, using an index of socioeconomic status is simpler than assessing household income or the value of household consumption. It is also relatively straightforward to compare the socioeconomic status of health program beneficiaries with a relevant reference population, although two independent surveys are required. Expressing relative wealth on a scale from zero to 100 is conceptually appealing, and the mean value of this rank score provides an equity-specific outcome measure readily integrated into the usual analytic framework for cluster-randomised trials.

To retain or remove user fees?: reflections on the current debate in low- and middle-income countries.

Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

CRTs--cluster randomized trials or "courting real troubles": challenges of running a CRT in rural Gujarat, India.

This paper addresses the logistical challenges of implementing public health interventions in the setting of cluster randomized trials (CRTs), drawing on the experience of carrying out a CRT within a community-based health insurance (CBHI) scheme in rural India. Our CRT is seeking to improve the equity impact--i.e., reduce the differential in claims submission for hospitalization between poor and less poor--of this CBHI in rural areas. Five main challenges are identified and discussed: 1) assigning control clusters, 2) blinding, 3) implementing interventions simultaneously, 4) minimizing leakage, and 5) piggy-backing on a changing scheme. These challenges are not likely to be unique to low-income settings, although the fifth challenge is particularly likely when working with relatively small and resource-constrained programs. While compromises to methodological best-practice may reduce internal validity, they make the intervention more 'real', and potentially more applicable, to other programs and settings. Further, careful documentation of compromises allows them to be considered in the final analysis.

Making health insurance work for the poor: learning from the Self-Employed Women's Association's (SEWA) community-based health insurance scheme in India.

How best to provide effective protection for the poorest against the financial risks of ill health remains an unanswered policy question. Community-based health insurance (CBHI) schemes, by pooling risks and resources, can in principal offer protection against the risk of medical expenses, and make accessible health care services that would otherwise be unaffordable. The purpose of this paper is to measure the distributional impact of a large CBHI scheme in Gujarat, India, which reimburses hospitalization costs, and to identify barriers to optimal distributional impact. The study found that the Vimo Self-employed Women's Association (SEWA) scheme is inclusive of the poorest, with 32% of rural members, and 40% of urban members, drawn from households below the 30th percentile of socio-economic status. Submission of claims for inpatient care is equitable in Ahmedabad City, but inequitable in rural areas. The financially better off in rural areas are significantly more likely to submit claims than are the poorest, and men are significantly more likely to submit claims than women. Members living in areas that have better access to health care submit more claims than those living in remote areas. A variety of factors prevent the poorest in rural and remote areas from accessing inpatient care or from submitting a claim. The study concludes that even a well-intentioned scheme may have an undesirable distributional impact, particularly if: (1) the scheme does not address the major barriers to accessing (inpatient) health care; and (2) the process of seeking reimbursement under the scheme is burdensome for the poor. Design and implementation of an equitable scheme must involve: a careful assessment of barriers to health care seeking; interventions to address the main barriers; and reimbursement requiring minimum paperwork and at the time/place of service utilization.

Impact on child mortality of removing user fees: simulation model.

OBJECTIVE: To estimate how many child deaths might be prevented if user fees were removed in 20 African countries DESIGN: Simulation model combining evidence on key health interventions' impacts on reducing child mortality with analysis of the effect of fee abolition on access to healthcare services. RESULTS: Elimination of user fees could prevent approximately 233,000 (estimate range 153,000-305,000) deaths annually in children aged under 5 in 20 African countries. CONCLUSION: Given the relatively low cost of abolition, replacing user fees with alternative financing mechanisms should be seen as an effective first step towards improving households' access to health care and achieving the millennium development goals for health.