Collective Intelligence-Based Participatory COVID-19 Surveillance in Accra, Ghana: Pilot Mixed Methods Study.

BACKGROUND: Infectious disease surveillance is difficult in many low- and middle-income countries. Information market (IM)-based participatory surveillance is a crowdsourcing method that encourages individuals to actively report health symptoms and observed trends by trading web-based virtual "stocks" with payoffs tied to a future event. OBJECTIVE: This study aims to assess the feasibility and acceptability of a tailored IM surveillance system to monitor population-level COVID-19 outcomes in Accra, Ghana. METHODS: We designed and evaluated a prediction markets IM system from October to December 2021 using a mixed methods study approach. Health care workers and community volunteers aged ≥18 years living in Accra participated in the pilot trading. Participants received 10,000 virtual credits to trade on 12 questions on COVID-19-related outcomes. Payoffs were tied to the cost estimation of new and cumulative cases in the region (Greater Accra) and nationwide (Ghana) at specified future time points. Questions included the number of new COVID-19 cases, the number of people likely to get the COVID-19 vaccination, and the total number of COVID-19 cases in Ghana by the end of the year. Phone credits were awarded based on the tally of virtual credits left and the participant's percentile ranking. Data collected included age, occupation, and trading frequency. In-depth interviews explored the reasons and factors associated with participants' user journey experience, barriers to system use, and willingness to use IM systems in the future. Trading frequency was assessed using trend analysis, and ordinary least squares regression analysis was conducted to determine the factors associated with trading at least once. RESULTS: Of the 105 eligible participants invited, 21 (84%) traded at least once on the platform. Questions estimating the national-level number of COVID-19 cases received 13 to 19 trades, and obtaining COVID-19-related information mainly from television and radio was associated with less likelihood of trading (marginal effect: -0.184). Individuals aged <30 years traded 7.5 times more and earned GH ¢134.1 (US $11.7) more in rewards than those aged >30 years (marginal effect: 0.0135). Implementing the IM surveillance was feasible; all 21 participants who traded found using IM for COVID-19 surveillance acceptable. Active trading by friends with communal discussion and a strong onboarding process facilitated participation. The lack of bidirectional communication on social media and technical difficulties were key barriers. CONCLUSIONS: Using an IM system for disease surveillance is feasible and acceptable in Ghana. This approach shows promise as a cost-effective source of information on disease trends in low- and middle-income countries where surveillance is underdeveloped, but further studies are needed to optimize its use.

Protocol for a randomized controlled trial on community education and surveillance on antibiotics use among young children in Nepal.

Background: Antimicrobial resistance (AMR) is one of the top ten threats to global health. There exists limited empirical evidence on effective approaches to address this threat. In low- and middle-income countries (LMICs), one of the primary drivers of AMR is easy access to antibiotics without prescriptions, in particular from community pharmacies. Interventions to reduce non-prescribed use of antibiotics and surveillance systems to track such usage are critically needed. This protocol describes a study that aims to test the effect of an educational intervention targeted to parents of young children on non-prescribed antibiotics consumption in Nepal and to track such consumption using a phone-based application. Methods: The study is a clustered randomized controlled trial, in which we randomly assign 40 urban wards of Kathmandu Valley to either treatment group or control group, and randomly select 24 households in each ward. Households in the treatment group will receive an education intervention consisting of an "AMR pitch" (an in-person interaction that lasts up to an hour) by community nurses, videos and text messages on AMR every two weeks, and a brochure. We will conduct a survey at baseline with the parents of children ages 6 months to 10 years and track consumption of antibiotics and health care use among these children for a period of 6 months using a phone-based application. Conclusion: While the study will primarily inform future policy and programmatic efforts to reduce AMR in Nepal, the study-both the education intervention and the surveillance system-can serve as a prototype for tackling AMR in other similar settings.

Economic and social drivers of antibiotic dispensing practices among community pharmacies in Nepal.

OBJECTIVE: To assess economic and social drivers of dispensing antibiotics without prescription by community pharmacies in Nepal. METHOD: A survey was conducted among 111 pharmacy owners and managers in five districts. Information on demographic and economic characteristics of the pharmacies (e.g. revenue and profits from antibiotics) and their inclination to sell antibiotics without a physician's prescription under various scenarios (e.g. diarrhoea in a child) was collected. Univariate analysis was conducted to assess the demographic and economic characteristics. Bivariate analysis was conducted to examine the relationship between dispensing antibiotics without prescription and economic and social factors. RESULTS: Azithromycin and amoxicillin were the most commonly dispensed antibiotics. The proportions of pharmacies reporting that they would 'most likely' or 'likely' dispense antibiotics without prescription to adult patients ranged from 36.9% (sore throat) to 67.6% (cough). The proportions for paediatric patients ranged from 62.2% (sore throat) to 80.2% (cough or diarrhoea). There was no consistent relationship between the likelihood of dispensing antibiotics and revenues, profits or the number of patients. Instead, dispensing behaviour was influenced by the pressure from the patient; the respondents were more likely to dispense antibiotics when the patient specifically asked for 'an antibiotic' rather than for 'a medicine', and 68.5% respondents ranked 'customer satisfaction' as the most important factor motivating their work. CONCLUSIONS: In Nepal, inappropriate sale of antibiotics by community pharmacists is high, particularly for paediatric patients. Additional research is needed to establish key drivers of this behaviour and to help design effective approaches to reducing AMR.

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.

Estimated cost for cardiovascular disease risk-based management at a primary healthcare center in Nepal.

Background: Low- and middle-income countries are facing an increasing burden of disability and death due to cardiovascular diseases. Policy makers and healthcare providers alike need resource estimation tools to improve healthcare delivery and to strengthen healthcare systems to address this burden. We estimated the direct medical costs of primary prevention, screening, and management for cardiovascular diseases in a primary healthcare center in Nepal based on the Global Hearts evidence based treatment protocols for risk-based management. Methods: We adapted the World Health Organization's non-communicable disease costing tool and built a model to predict the annual cost of primary CVD prevention, screening, and management at a primary healthcare center level. We used a one-year time horizon and estimated the cost from the Nepal government's perspective. We used Nepal health insurance board's price for medicines and laboratory tests, and used Nepal government's salary for human resource cost. With the model, we estimated annual incremental cost per case, cost for the entire population, and cost per capita. We also estimated the amount of medicines for one-year, annual number of laboratory tests, and the monthly incremental work load of physicians and nurses who deliver these services. Results: For a primary healthcare center with a catchment population of 10,000, the estimated cost to screen and treat 50% of eligible patients is USD21.53 per case and averages USD1.86 per capita across the catchment population. The cost of screening and risk profiling only was estimated to be USD2.49 per case. At same coverage level, we estimated that an average physician's workload will increase annually by 190 h and by 111 h for nurses, i.e., additional 28.5 workdays for physicians and 16.7 workdays for nurses. The total annual cost could amount up to USD18,621 for such a primary healthcare center. Conclusion: This is a novel study for a PHC-based, primary CVD risk-based management program in Nepal, which can provide insights for programmatic and policy planners at the Nepalese municipal, provincial and central levels in implementing the WHO Global Hearts Initiative. The costing model can serve as a tool for financial resource planning for primary prevention, screening, and management for cardiovascular diseases in other low- and middle-income country settings globally.

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.