How countries can reduce child stunting at scale: lessons from exemplar countries.

BACKGROUND: Child stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress. OBJECTIVES: To synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting. METHODS: We did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition. RESULTS: Several countries have dramatically reduced child stunting prevalence, with or without closing geographical, economic, and other population inequalities. Countries made progress through interventions from within and outside the health sector, and despite significant heterogeneity and differences in context, contributions were comparable from health and nutrition sectors (40% of change) and other sectors (50%), previously called nutrition-specific and -sensitive strategies. Improvements in maternal education, maternal nutrition, maternal and newborn care, and reductions in fertility/reduced interpregnancy intervals were strong contributors to change. A roadmap to reducing child stunting at scale includes several steps related to diagnostics, stakeholder consultations, and implementing direct and indirect nutrition interventions related to the health sector and nonhealth sector . CONCLUSIONS: Our results show that child stunting reduction is possible even in diverse and challenging contexts. We propose that our framework of organizing nutrition interventions as direct/indirect and inside/outside the health sector should be considered when mapping causal pathways of child stunting and planning interventions and strategies to accelerate stunting reduction to achieve the 2030 Sustainable Development Goals.

Resource requirements for essential universal health coverage: a modelling study based on findings from Disease Control Priorities, 3rd edition.

BACKGROUND: Disease Control Priorities, 3rd edition (DCP3), published two model health benefits packages (HBPs). This study estimates the overall costs and individual component costs of these packages in low-income countries (LICs) and lower-middle-income countries (lower-MICs). METHODS: This study reports on our Disease Control Priorities Cost Model (DCP-CM), developed as part of the DCP3 project to determine the overall costs of the 218 health sector interventions recommended in the model HBP termed essential universal health coverage (EUHC). Model inputs included data on intervention unit costs, demographic and epidemiological data to quantify the populations in need of specific interventions, baseline coverage indicators, and estimates of required health system costs to support direct service delivery. The DCP-CM was informed primarily by published estimates of economic costs of interventions measured from the health system perspective. We estimated counterfactual annual costs for the year 2015. We disaggregated costs according to intervention characteristics (delivery platform, delivery timing, and health system objective) and did one-way and probabilistic sensitivity analyses with determination of 95% credible intervals (Crls). FINDINGS: At 80% population coverage, the annual cost of EUHC would be US$79 (95% Crl 60-110) per capita (in 2016 US dollars) in LICs and US$130 (100-180) per capita in lower-MICs. As a share of 2015 gross national income (GNI), additional investments would require 8·0% (95% Crl 5·7-11·3) in LICs and 4·2% (2·9-5·9) in lower-MICs. A highest priority subpackage comprising 115 of the EUHC interventions would cost approximately half of these amounts (3·7% [2·6-5·3] of 2015 GNI in LICs and 2·0% [1·4-2·8] in lower-MICs). Mortality-reducing interventions would require around two-thirds of the overall package costs, with interventions to reduce mortality at age 5-69 years from non-communicable disease and injury comprising the highest share of total EUHC costs in both income groups (37·6% [37·2-37·9] in LICs and 43·0% [42·6-43·4] in lower-MICs). Interventions addressing chronic health conditions (requiring 45·5% [44·8-46·4] 2015 GNI for LICs and lower-MICs combined) and interventions delivered in health centres (requiring 49·8% [49·5-50·2] 2015 GNI for LICs and lower-MICs combined) would each comprise the plurality of costs. INTERPRETATION: Implementation of EUHC would require costly investment, especially in LICs. DCP-CM is available as an online tool that can inform local HBP deliberation and support efficient investment in UHC, especially as countries pivot towards non-communicable disease and injury care. FUNDING: Bill & Melinda Gates Foundation, Trond Mohn Foundation, and Norwegian Agency for Development Cooperation.

Sustainable care for children with cancer: a Lancet Oncology Commission.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

The cost and cost-effectiveness of childhood cancer treatment in El Salvador, Central America: A report from the Childhood Cancer 2030 Network.

BACKGROUND: Although previous studies have examined the cost of treating individual childhood cancers in low-income and middle-income countries, to the authors' knowledge none has examined the overall cost and cost-effectiveness of operating a childhood cancer treatment center. Herein, the authors examined the cost and sources of financing of a pediatric cancer unit in Hospital Nacional de Ninos Benjamin Bloom in El Salvador, and make estimates of cost-effectiveness. METHODS: Administrative data regarding costs and volumes of inputs were obtained for 2016 for the pediatric cancer unit. Similar cost and volume data were obtained for shared medical services provided centrally (eg, blood bank). Costs of central nonmedical support services (eg, utilities) were obtained from hospital data and attributed by inpatient share. Administrative data also were used for sources of financing. Cost-effectiveness was estimated based on the number of new patients diagnosed annually and survival rates. RESULTS: The pediatric cancer unit cost $5.2 million to operate in 2016 (treating 90 outpatients per day and experiencing 1385 inpatient stays per year). Approximately three-quarters of the cost (74.7%) was attributed to 4 items: personnel (21.6%), pathological diagnosis (11.5%), pharmacy (chemotherapy, supportive care medications, and nutrition; 31.8%), and blood products (9.8%). Funding sources included government (52.5%), charitable foundations (44.2%), and a social security contribution scheme (3.4%). Based on 181 new patients per year and a 5-year survival rate of 48.5%, the cost per disability-adjusted life-year averted was $1624, which is under the threshold considered to be very cost effective. CONCLUSIONS: Treating childhood cancer in a specialized unit in low-income and middle-income countries can be done cost-effectively. Strong support from charitable foundations aids with affordability. Cancer 2018;124:391-7. © 2017 American Cancer Society.

Strengthening implementation and utilization of nutrition interventions through research: a framework and research agenda.

Undernutrition among women and children contributes to almost half the global burden of child mortality in developing countries. The impact of nutrition on economic development has highlighted the need for evidence-based solutions and yielded substantial global momentum. However, it is now recognized that the impact of evidence-based interventions is limited by the lack of evidence on the best operational strategies for scaling up nutrition interventions. With the goal of encouraging greater engagement in implementation research in nutrition and generating evidence on implementation and utilization of nutrition interventions, this paper brings together a framework and a broad analysis of literature to frame and highlight the crucial importance of research on the delivery and utilization of nutrition interventions. The paper draws on the deliberations of a high-level working group, an e-consultation, a conference, and the published literature. It proposes a framework and areas of research that have been quite neglected, and yet are critical to better understanding through careful research to enable better translation of global and national political momentum for nutrition into public health impact.

Weekly iron-folic acid supplementation with regular deworming is cost-effective in preventing anaemia in women of reproductive age in Vietnam.

BACKGROUND: To estimate the cost and cost-effectiveness of a project administering de-worming and weekly iron-folic acid supplementation to control anaemia in women of reproductive age in Yen Bai province, Vietnam. METHODS AND FINDINGS: Cost effectiveness was evaluated using data on programmatic costs based on two surveys in 2006 and 2009 and impact on anaemia and iron status collected in 2006, 2007, and 2008. Data on initial costs for training and educational materials were obtained from the records of the National Institute of Malariology, Parasitology and Entomology and the Yen Bai Malaria Control Program. Structured questionnaires for health workers at district, commune and village level were used to collect ongoing distribution and monitoring costs, and for participants to collect transport and loss of earnings costs. The cost per woman treated (defined as consuming at least 75% of the recommended intake) was USD0.76 per annum. This estimate includes financial costs (for supplies, training), and costs of health care workers' time. Prevalence of anaemia fell from 38% at baseline, to 20% after 12 months. Thus, the cost-effectiveness of the project is assessed at USD 4.24 per anaemia case prevented per year. Based on estimated productivity gains for adult women, the benefit:cost ratio is 6.7∶1. Cost of the supplements and anthelminthics was 47% of the total, while costs of training, monitoring, and health workers' time accounted for 53%. CONCLUSION: The study shows that weekly iron-folic acid supplementation and regular de-worming is a low-cost and cost-effective intervention and would be appropriate for population-based introduction in settings with a high prevalence of anaemia and iron deficiency and low malaria infection rates.

Economic gains of a home fortification program: evaluation of "Sprinkles" from the provider's perspective.

INTRODUCTION: This paper models the effects of a home-fortification program (using Sprinkles which contain zinc and iron and other micronutrients), in Pakistan, a country with high levels of infant mortality, anemia, and diarrhea. It uses the results of randomized trials of the effect of Sprinkles on anemia and on longitudinal prevalence of diarrhea. METHODS: Based on previous literature, the effect of Sprinkles on intermediate outcomes (diarrhea and anemia) is linked to longer-term outcomes (infant and young child mortality, and cognitive achievement and hence adult wages). Three different measures of cost effectiveness are presented: the cost per death averted (effect via zinc supplementation on reduction of longitudinal prevalence of diarrhea); the cost per 'disability adjusted life year' (DALY) saved (same modality); and the gain in earnings due to higher cognitive functioning for each dollar spent (effect via iron supplementation on reduced anemia). RESULTS: We estimated that the cost per death averted is dollars406 (dollars273-dollars3248), the cost per DALY saved is dollars12.2 (dollars8-dollars97) and the present value of the gain in earnings is dollars37 (dollars18-dollars51) for each dollar spent on the Sprinkles program. These estimates were developed for a low-income country (GDP per capita = dollars417) with a high infant mortality rate (IMR = 83/1000), high prevalence of anemia (93%), and high mean longitudinal prevalence of diarrhea (17%). DISCUSSION: These outcomes are particularly favourable in Pakistan. The outcomes are more favourable when used with children 6-12 months. Further longer-run field trials of Sprinkles with larger populations would be helpful.