The costs of Suaahara II, a complex scaled-up multisectoral nutrition programme in Nepal.

Limited evidence exists on the costs of scaled-up multisectoral nutrition programmes. Such evidence is crucial to assess intervention value and affordability. Evidence is also lacking on the opportunity costs of implementers and participants engaging in community-level interventions. We help to fill this gap by estimating the full financial and economic costs of the United States Agency for International Development-funded Suaahara II (SII) programme, a scaled-up multisectoral nutrition programme in Nepal (2016-2023). We applied a standardized mixed methods costing approach to estimate total and unit costs over a 3.7-year implementation period. Financial expenditure data from national and subnational levels were combined with economic cost estimates assessed using in-depth interviews and focus group discussions with staff, volunteers, community members, and government partners in four representative districts. The average annual total cost was US$908,948 per district, with economic costs accounting for 47% of the costs. The annual unit cost was US$132 per programme participant (mother in the 1000-day period between conception and a child's second birthday) reached. Annual costs ranged from US$152 (mountains) to US$118 (plains) per programme participant. Personnel (63%) were the largest input cost driver, followed by supplies (11%). Community events (29%) and household counselling visits (17%) were the largest activity cost drivers. Volunteer cadres contributed significant time to the programme, with female community health volunteers spending a substantial amount of time (27 h per month) on SII activities. Multisectoral nutrition programmes can be costly, especially when taking into consideration volunteer and participant opportunity costs. This study provides much-needed evidence of the costs of scaled-up multisectoral nutrition programmes for future comparison against benefits.

Global VAX: A U.S. contribution to global COVID-19 vaccination efforts, 2021-2023.

In December 2021 the U.S. Government announced a new, whole-of-government $1.8 billion effort, the Initiative for Global Vaccine Access (Global VAX) in response to the global COVID-19 pandemic. Using the foundation of decades of U.S. government investments in global health and working in close partnership with local governments and key global and multilateral organizations, Global VAX enabled the rapid acceleration of the global COVID-19 vaccine rollout in selected countries, contributing to increased COVID-19 vaccine coverage in some of the world's most vulnerable communities. Through Global VAX, the U.S. Government has supported 125 countries to scale up COVID-19 vaccine delivery and administration while strengthening primary health care systems to respond to future health crises. The progress made by Global VAX has paved the way for a stronger global recovery and improved global health security.

Outcomes for Arthroplasties in Military Health: A Retrospective Analysis of Direct Versus Purchased Care.

INTRODUCTION: The Department of Defense is reforming the military health system where surgeries are increasingly referred from military treatment facilities (MTFs) with direct care to higher-volume civilian hospitals under purchased care. This shift may have implications on the quality and cost of care for TRICARE beneficiaries. This study examined the impact of care source and surgical volume on perioperative outcomes and cost of total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). MATERIALS AND METHODS: We examined TRICARE claims for patients who underwent THA or TKA between 2006 and 2019. The 30-day readmissions, complications, and costs between direct and purchased care were evaluated using the logistic regression model for surgical outcomes and generalized linear models for cost. RESULTS: We included 71,785 TKA and THA procedures. 11,013 (15.3%) were performed in direct care. They had higher odds of readmissions (odds ratio, OR 1.29 [95% CI, 1.12-1.50]; P < 0.001) but fewer complications (OR 0.83 [95% CI, 0.75-0.93]; P = 0.002). Within direct care, lower-volume facilities had more complications (OR 1.27 [95% CI, 1.01-1.61]; P = 0.05). Costs for index surgeries were significantly higher at MTFs $26,022 (95% CI, $23,393-$28,948) vs. $20,207 ($19,339-$21,113). Simulating transfer of care to very high-volume MTFs, estimated cost savings were $4,370/patient and $20,229,819 (95% CI, $17,406,971-$25,713,571) in total. CONCLUSIONS: This study found that MTFs are associated with lower odds of complications, higher odds of readmission, and higher costs for THA and TKA compared to purchased care facilities. These findings mean that care in the direct setting is adequate and consolidating care at higher-volume MTFs may reduce health care costs.

Measurement of benefits in economic evaluations of nutrition interventions in low- and middle-income countries: A systematic review.

Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority-setting. However, there are unique challenges to synthesizing the findings of multi-sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost-effectiveness, cost-utility and benefit-cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low- and middle-income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty-seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty-one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non-health and multi-sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.

Scaling up nutrition through multisectoral planning: An exploratory review of 26 national nutrition plans.

With a growing consensus on the need to address malnutrition in a comprehensive and multisectoral way, there has been increased attention on the processes and factors for multisectoral nutrition planning to be successful. To guide countries, the Scaling Up Nutrition (SUN) Movement developed a checklist that defined characteristics of good national nutrition plans. This exploratory review used the framework of the Checklist to assess 26 national multisectoral nutrition plans (MSNPs) developed between 2014 and 2020. The MSNPs were assessed against a subset of 31 Checklist characteristics defined as basic plan components. Although the level of detail varied across the reviewed plans, the majority included core components that are important to facilitate effective planning and implementation, such as an assessment of the nutritional status and determinants of malnutrition for children under 5 years of age, a commitment to global recommendations related to reducing malnutrition, actions consistent with global evidence and responding to identified issues/gaps, governance arrangements to facilitate coordination, and identification of capacity-building needs/actions to support effective implementation. Common gaps across plans included risk analysis and mitigation, defined responsible agencies for each action, an assessment of the financial gap and defined mechanisms for financial tracking and resource allocation, and mechanisms to coordinate operational research. These findings provide a high-level, multi-country review of multisectoral nutrition planning that can support future policymakers, technical assistance providers and regional and global stakeholders to consider the foundational elements of and further validate and address common shortcomings in developing such a plan.

Is the current referral trend a threat to the Military Health System? Perioperative outcomes and costs after colorectal surgery in the Military Health System versus civilian facilities.

BACKGROUND: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries. METHODS: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care. RESULTS: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916). CONCLUSION: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications.

Trends in Surgical Volume in the Military Health System-A Potential Threat to Mission Readiness.

INTRODUCTION: The Military Health System (MHS) is tasked with a dual mission both to provide medical services for covered patients and to ensure that its active duty medical personnel maintain readiness for deployment. Knowledge, skills, and attitudes (KSA) is a metric evaluating the transferrable skills incorporated into a given surgery or medical procedure that are most relevant for surgeons deployed to a theatre of war. Procedures carrying a high KSA value are those utilizing skills with high relevance for maintaining deployment readiness. Given ongoing concerns regarding surgical volumes at MTFs and the potential adverse impact on military surgeon mission readiness were high-value surgeries to be lost to the civilian sector, we evaluated trends in the setting of high-value surgeries for beneficiaries within the MHS. METHODS: We retrospectively analyzed inpatient admissions data from MTFs and TRICARE claims data from civilian hospitals, 2005-2019, to identify TRICARE-covered patients covered under "purchased care" (referred to civilian facilities) or receiving "direct care" (undergoing treatment at MTFs) and undergoing seven high-value/high-KSA surgeries: colectomy, pancreatectomy, hepatectomy, open carotid endarterectomy, abdominal aortic aneurysm (AAA) repair, esophagectomy, and coronary artery bypass grafting (CABG). Overall and procedure-specific counts were captured, MTFs were categorized into quartiles by volume, and independence between trends was tested with a Cochran-Armitage test, hypothesizing that the proportion of cases referred for purchased care was increasing. RESULTS: We captured 292,411 cases, including 7,653 pancreatectomies, 4,177 hepatectomies, 3,815 esophagectomies, 112,684 colectomies, 92,161 CABGs, 26,893 AAA repairs, and 45,028 carotid endarterectomies. The majority of cases included were referred for purchased care (90.3%), with the proportion of cases referred increasing over the study period (P < .01). By procedure, all cases except AAA repairs were increasingly referred for treatment over the study period (all P < .01, except esophagectomy P = .04). On examining volume, we found that even the highest-volume-quartile MTFs performed a median of less than one esophagectomy, hepatectomy, or pancreatectomy per month. The only included procedure performed once a month or more at the majority of MTFs was CABG. CONCLUSION: On examining volume and referral trends for high-value surgeries within the MHS, we found low surgical volumes at the vast majority of included MTFs and an increasing proportion of cases referred to civilian hospitals over the last 15 years. Our findings illustrate missed opportunities for maintaining the mission readiness of military surgical personnel. Prioritizing the recapture of lost surgical volume may improve the surgical teams' mission readiness.

Perspectives on Implementation Considerations and Costs of Malaria Case Management Supportive Supervision.

Between 2012 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported national malaria control programs in sub-Saharan Africa to implement a case management quality assurance (QA) system for malaria and other febrile illnesses. A major component of the system was outreach training and supportive supervision (OTSS), whereby trained government health personnel visited health facilities to observe health-care practices using a standard checklist, to provide individualized feedback to staff, and to develop health facility-wide action plans based on observation and review of facility registers. Based on MalariaCare's experience, facilitating visits to more than 5,600 health facilities in nine countries, we found that programs seeking to implement similar supportive supervision schemes should consider ensuring the following: 1) develop a practical checklist that balances information gathering and mentorship; 2) establish basic competency criteria for supervisors and periodically assess supervisor performance in the field; 3) conduct both technical skills training and supervision skills training; 4) establish criteria for selecting facilities to conduct OTSS and determine the appropriate frequency of visits; and 5) use electronic data collection systems where possible. Cost will also be a significant consideration: the average cost per OTSS visit ranged from $44 to $333. Significant variation in costs was due to factors such as travel time, allowances for government personnel, length of the visit, and involvement of central level officials. Because the cost of conducting supportive supervision prohibits regularly visiting all health facilities, internal QA measures could also be considered as alternative or complementary activities to supportive supervision.

Effect of Supportive Supervision on Malaria Microscopy Competencies in Sub-Saharan Africa.

Although light microscopy is the reference standard for diagnosing malaria, maintaining skills over time can be challenging. Between 2015 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported outreach training and supportive supervision (OTSS) visits at 1,037 health facilities in seven African countries to improve performance in microscopy slide preparation, staining, and reading. During these visits, supervisors observed and provided feedback to health-care workers (HCWs) performing malaria microscopy using a 30-step checklist. Of the steps observed in facilities with at least three visits, the proportion of HCWs that performed each step correctly at baseline ranged from 63.2% to 94.2%. The change in the proportion of HCWs performing steps correctly by the third visit ranged from 16.7 to 23.6 percentage points (n = 916 observations). To assess the overall improvement, facility scores were calculated based on the steps performed correctly during each visit. The mean score at baseline was 85.7%, demonstrating a high level of performance before OTSS. Regression analysis predicted an improvement in facility scores of 3.6 percentage points (P < 0.001) after three visits across all countries. In reference-level facilities with consistently high performance on microscopy procedures and parasite detection, quality assurance (QA) mechanisms could prioritize more advanced skills, such as proficiency testing for parasite counting and species identification. However, in settings with high staff turnover and declining use of microscopy in favor of rapid diagnostic tests, additional supervision visits and/or additional QA measures may be required to improve and maintain performance.

Introduction and Evaluation of an Electronic Tool for Improved Data Quality and Data Use during Malaria Case Management Supportive Supervision.

Although on-site supervision programs are implemented in many countries to assess and improve the quality of care, few publications have described the use of electronic tools during health facility supervision. The President's Malaria Initiative-funded MalariaCare project developed the MalariaCare Electronic Data System (EDS), a custom-built, open-source, Java-based, Android application that links to District Health Information Software 2, for data storage and visualization. The EDS was used during supervision visits at 4,951 health facilities across seven countries in Africa. The introduction of the EDS led to dramatic improvements in both completeness and timeliness of data on the quality of care provided for febrile patients. The EDS improved data completeness by 47 percentage points (42-89%) on average when compared with paper-based data collection. The average time from data submission to a final data analysis product dropped from over 5 months to 1 month. With more complete and timely data available, the Ministry of Health and the National Malaria Control Program (NMCP) staff could more effectively plan corrective actions and promptly allocate resources, ultimately leading to several improvements in the quality of malaria case management. Although government staff used supervision data during MalariaCare-supported lessons learned workshops to develop plans that led to improvements in quality of care, data use outside of these workshops has been limited. Additional efforts are required to institutionalize the use of supervision data within ministries of health and NMCPs.

Effect of Supportive Supervision on Performance of Malaria Rapid Diagnostic Tests in Sub-Saharan Africa.

Rapid diagnostic tests (RDTs) are one of the primary tools used for parasitological confirmation of suspected cases of malaria. To ensure accurate results, health-care workers (HCWs) must conduct the RDT test correctly. Trained supervisors visited 3,603 facilities to assess RDT testing performance and conduct outreach training and supportive supervision activities in eight African countries between 2015 and 2017, using a 12-point checklist to determine if key steps were being performed. The proportion of HCWs performing each step correctly improved between 1.1 and 21.0 percentage points between the first and third visits. Health-care worker scores were averaged to calculate facility scores, which were found to be high: the average score across all facilities was 85% during the first visit and increased to 91% during the third visit. A regression analysis of these facility scores estimated that, holding key facility factors equal, facility performance improved by 5.3 percentage points from the first to the second visit (P < 0.001), but performance improved only by 0.6 percentage points (P = 0.10) between the second and third visits. Factors strongly associated with higher scores included the presence of a laboratory worker at the facility and the presence of at least one staff member with previous formal training in malaria RDTs. Findings confirm that a comprehensive quality assurance system of training and supportive supervision consistently, and often significantly, improves RDT performance.

Effect of Supportive Supervision on Competency of Febrile Clinical Case Management in Sub-Saharan Africa.

Since 2010, the WHO has recommended that clinical decision-making for malaria case management be performed based on the results of a parasitological test result. Between 2015 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported the implementation of this practice in eight sub-Saharan African countries through 5,382 outreach training and supportive supervision visits to 3,563 health facilities. During these visits, trained government supervisors used a 25-point checklist to observe clinicians' performance in outpatient departments, and then provided structured mentoring and action planning. At baseline, more than 90% of facilities demonstrated a good understanding of WHO recommendations-when tests should be ordered, using test results to develop an accurate final diagnosis, severity assessment, and providing the correct prescription. However, significant deficits were found in history taking, conducting a physical examination, and communicating with patients and their caregivers. After three visits, worker performance demonstrated steady improvement-in particular, with checking for factors associated with increased morbidity and mortality: one sign of severe malaria (72.9-85.5%), pregnancy (81.1-87.4%), and anemia (77.2-86.4%). A regression analysis predicted an overall improvement in clinical performance of 6.3% (P < 0.001) by the third visit. These findings indicate that in most health facilities, there is good baseline knowledge on the processes of quality clinical management, but further training and on-site mentoring are needed to improve the clinical interaction that focuses on second-order decision-making, such as severity of illness, management of non-malarial fever, and completing the patient-provider communication loop.

Understanding the process of strengthening multi-sectoral efforts for anemia reduction: Qualitative findings from Sierra Leone and Uganda.

Anemia is a significant global health problem, and progress to reduce it has been slow. A multi-sectoral, context-specific, and country-led approach is recommended to effectively address anemia, but there is limited documentation of how this has worked in practice. We present key findings and lessons learned from Sierra Leone and Uganda's experiences establishing national-level anemia coordination platforms. A longitudinal collective case study methodology was used, with in-depth interviews of National Anemia Working Group members in both countries; data was analyzed to distill the salient lessons learned across countries. Similar factors were identified in the 2 countries. Setting the agenda was an important first step, accomplished by using country-specific anemia-related data and obtaining multi-sectoral commitment. Establishment of a cohesive coordination structure provided an effective platform to prioritize and align anemia activities. Strong, committed leadership and representation of diverse stakeholders was essential to maintain the legitimacy of anemia efforts. The main barriers to the policy-making process included misalignment of sectoral mandates, differences in work cultures, as well as competing priorities and increased staff workload. Sierra Leone and Uganda's experiences contribute to the global evidence base for anemia coordination and planning at the national level, particularly around linking health and non-health sectors and developing multi-sectoral platforms. It remains to be seen how and to what extent resulting policies in Sierra Leone and Uganda will translate to implementation.

Prioritizing and Funding Nepal's Multisector Nutrition Plan.

BACKGROUND: Nepal has a long tradition of designing good multisectoral nutrition policy. However, success of policy implementation has varied. More evidence on how to successfully carry out multisector nutrition policy is needed. OBJECTIVE: We tracked the influence of Nepal's multisectoral nutrition plan (MSNP) on the process of priority setting and budgeting from 2014 to 2016. METHODS: This study used a mixed-method longitudinal design to track qualitative and budgetary changes related to MSNP processes nationally as well as in 3 districts. Qualitative changes in each study area were assessed through interviews, observation, news content, and meeting notes. Changes in allocations and expenditures were calculated based on budget documents, work plans, and validation interviews. RESULTS: Improved understanding of the MSNP was documented nationally and in study districts but not in VDCs. Human resources, ownership, bottom-up planning, coordination, advocacy, and sustainable structures all emerged as important factors within the enabling environment. Evidence suggests the MSNP influenced improvements in the last 3 factors. We also found notable increases in activities and financing for nutrition-allocations increased steadily between FY 2013-2014 and FY 2015-2016, and 28% of total nutrition allocations in the final year came from new or expanded MSNP-affiliated activities. Data from 3 districts highlight challenges linking local planning and budgeting to central-level structures. CONCLUSIONS: The MSNP appears to have strengthened the nutrition system in Nepal and increased priority and funding for nutrition. Next steps include strengthening linkages to the districts and below. Other countries can learn from the MSNP's success in increasing investment for nutrition.