Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services.

The global burden of non-communicable diseases (NCDs) is growing, and there is an urgent need to estimate the costs and benefits of an investment strategy to prevent and control NCDs. Results from an investment-case analysis can provide important new evidence to inform decision making by governments and donors. We propose a methodology for calculating the economic benefits of investing in NCDs during the Sustainable Development Goals (SDGs) era, and we applied this methodology to cardiovascular disease prevention in 20 countries with the highest NCD burden. For a limited set of prevention interventions, we estimated that US$120 billion must be invested in these countries between 2015 and 2030. This investment represents an additional $1·50 per capita per year and would avert 15 million deaths, 8 million incidents of ischaemic heart disease, and 13 million incidents of stroke in the 20 countries. Benefit-cost ratios varied between interventions and country-income levels, with an average ratio of 5·6 for economic returns but a ratio of 10·9 if social returns are included. Investing in cardiovascular disease prevention is integral to achieving SDG target 3.4 (reducing premature mortality from NCDs by a third) and to progress towards SDG target 3.8 (the realisation of universal health coverage). Many countries have implemented cost-effective interventions at low levels, so the potential to achieve these targets and strengthen national income by scaling up these interventions is enormous.

Postpartum hemorrhage prevention in Nepal: a program assessment.

BACKGROUND: In 2009, the Nepal Ministry of Health and Population launched a national program for prevention of postpartum hemorrhage (PPH) during home births that features advance distribution of misoprostol to pregnant women. In the years since, the government has scaled-up the program throughout much of the country. This paper presents findings from the first large-scale assessment of the effectiveness of the advance distribution program. METHODS: Data collection was carried out in nine districts and all three ecological zones. To assess knowledge, receipt and use of misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months. To assess supply and provision of misoprostol, interviews were conducted with 270 Female Community Health Volunteers (FCHVs) and staff at 99 health facilities. RESULTS: Among recently delivered women, only 15% received information about misoprostol and 13% received misoprostol tablets in advance of delivery. Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year. About one-half of FCHVs were providing incomplete information about the use of misoprostol; in addition, many did not discuss side effects, how to recognize PPH or where to go if PPH occurs. Among health facilities, just one-half had sufficient misoprostol stock, while 95% had sufficient oxytocin stock, at the time of this assessment. CONCLUSIONS: In Nepal, women who receive advance misoprostol are both willing and able to use the medication for PPH prevention during home births. However the supply and personnel challenges identified raise questions about scalability and impact of the program over the long-term. Further assessment is needed.

Promotion and prelacteal feeding of breastmilk substitutes among mothers in Kathmandu Valley, Nepal.

UNLABELLED: In 1992, Nepal passed the Mother's Milk Substitutes (Control of Sale and Distribution) Act in order to regulate the sale, distribution and promotion of substitutes for breastmilk within Nepal, in an effort to protect and promote breastfeeding. Helen Keller International, in collaboration with Nepal's Ministry of Health and Population's Child Health Division, implemented a study to assess mothers' exposure to promotions for and utilization of breastmilk substitutes in Kathmandu Valley, Nepal. A health facility-based, cross-sectional survey was conducted among 304 mothers being discharged after delivery. Prelacteal feeding of breastmilk substitutes is prevalent (55.9% of mothers, n = 170). Reported recommendations during antenatal checks and after delivery from health professionals to use breastmilk substitutes were prevalent, occurring among 47.4% (n = 144) of mothers; rates of these recommendations were significantly higher for mothers that delivered in private health facilities, as compared with public (67.7% vs. 38.0%, P < 0.001). Mothers that received a recommendation to use a breastmilk substitute from a health worker were 16.7 times more likely to provide a prelacteal feed of a breastmilk substitute, as compared with mothers that did not receive a recommendation (P < 0.001). Few mothers reported observation of commercial advertisements for breastmilk substitutes inside a health facility (reported by 3.6% of mothers). No mothers reported receiving a sample of a breastmilk substitute, bottle or teat from a health professional. More information is needed to determine why there is such a high rate of health worker recommendations for breastmilk substitute use in the first few days after delivery. KEY MESSAGES: While utilization of breastmilk substitutes is low among mothers of young children in Nepal, prelacteal feeding of breastmilk substitutes is highly prevalent in Kathmandu Valley. Reported recommendations from health professionals to use breastmilk substitutes are common (over 40%) and are associated with prelacteal feeding among Nepal mothers included in this study. Provision of lactation management training to health workers and monitoring their practices regularly could strengthen breastfeeding counselling, aid in reducing high rates of prelacteal feeding and contribute to improved infant feeding practices.

High consumption of commercial food products among children less than 24 months of age and product promotion in Kathmandu Valley, Nepal.

Commercially produced complementary foods can help improve nutritional status of young children if they are appropriately fortified and of optimal nutrient composition. However, other commercially produced snack food products may be nutritionally detrimental, potentially increasing consumption of foods high in salt or sugar and displacing consumption of other more nutritious options. Helen Keller International, in collaboration with the Nepal government, implemented a study to assess mothers' utilization of commercial food products for child feeding and exposure to commercial promotions for these products. A cross-sectional survey was conducted among 309 mothers of children less than 24 months of age across 15 health facilities. Utilization of breastmilk substitutes was low, having been consumed by 6.2% of children 0-5 months of age and 7.5% of children 6-23 months of age. Approximately one-fourth (24.6%) of children 6-23 months age had consumed a commercially produced complementary food in the prior day. Twenty-eight percent of mothers reported observing a promotion for breastmilk substitutes, and 20.1% reported promotions for commercially produced complementary foods. Consumption of commercially produced snack food products was high at 74.1% of children 6-23 months. Promotions for these same commercially produced snack food products were highly prevalent in Kathmandu Valley, reported by 85.4% of mothers. In order to improve diets during the complementary feeding period, development of national standards for complementary food products is recommended. Nutritious snack options should be promoted for the complementary feeding period; consumption of commercially produced snack food products high in sugar and salt and low in nutrients should be discouraged.

Strengthening policy and governance to address the growing burden of diabetes in Nepal.

Diabetes poses a major challenge to Nepal's health-care system. Deaths due to noncommunicable diseases (NCDs) have increased from 51% of all deaths in the country in 2010 to 60% in 2014. In 2014, diabetes and other essential NCDs accounted for 46% of the total deaths and 22% of premature deaths in the country. As diabetes is common in adults of working age, the impact will further impoverish individuals and families in Nepal, where out-of-pocket expenditure for health remains high. To halt the rise in diabetes and obesity, the government of Nepal will have to adopt a public health approach that balances individual and population-level interventions. Awareness, early diagnosis and prevention are key to management and control of diabetes. To date, there has been no nationwide robust programme for diabetes prevention in the country and services are inaccessible to much of the Nepalese population. However, under the NCD Multisectoral Action Plan (2014-2020), there will be phase-wise implementation of the World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings. The NCD PEN brings opportunities to strengthen the health workforce, diagnostics, medicines and supplies, the health information system, and research and surveillance and to reduce inequity in diabetes care in Nepal.