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Child mortality measurement is essential to the impact evaluation of maternal and child healthcare systems interventions. In the absence of vital statistics systems, however, assessment methodologies for locally relevant interventions are severely challenged. Methods for assessing the under-5 mortality rate for cross-country comparisons, often used in determining progress towards development targets, pose challenges to implementers and researchers trying to assess the population impact of targeted interventions at more local levels. Here, we discuss the programmatic approach we have taken to mortality measurement in the context of delivering healthcare via a public–private partnership in rural Nepal. Both government officials and the delivery organisation, Possible, felt it was important to understand child mortality at a fine-grain spatial and temporal level. We discuss both the short-term and the long-term approach. In the short term, the team chose to use the under-2 mortality rate as a metric for mortality measurement for the following reasons: (1) as overall childhood mortality declines, like it has in rural Nepal, deaths concentrate among children under the age of 2; (2) 2-year cohorts are shorter and thus may show an impact more readily in the short term of intervention trials; and (3) 2-year cohorts are smaller, making prospective census cohorts more feasible in small populations. In the long term, Possible developed a digital continuous surveillance system to capture deaths as they occur, at which point under-5 mortality assessment would be desirable, largely owing to its role as a global standard.

Background: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe. Objectives: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings. Methods: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework. Results: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships. Conclusions: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: A. Tiwari and A. Thapa are employed by a US-based non-profit (Possible) and based in Nepal. S. Sapkota and R. Khatri are employed by a Nepal-based non-governmental organization, Possible that operates with support from US-based Possible. VB, BB, HJR, R. Paudel, SG, NM, R. Poudel and LDB are employed by a Nepal-based non-governmental organization (Nyaya Health Nepal) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic, and private foundation sources. NC, DM, SM are employed by, and SM, DC, DM, and S. Sapkota are faculty members at a private medical school (Icahn School of Medicine at Mount Sinai). DM is a member on US-based Possible’s Board of Directors, for which he receives no compensation. IB is a board chair of Nepal-based Possible. WW is a faculty member at a private university (Boston University School of Medicine). DC is a faculty member and SH is a graduate student at a public university (University of Washington). R. Schwarz is employed at an academic medical center (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. R. Schwarz is a faculty member at a private medical school (Harvard Medical School) and employed at an academic medical center (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. SA is a faculty member at a private medical school (NYU School of Medicine). SK is a nursing student at Gandaki Medical College Teaching Hospital and Research Center. IN is a graduate student at a private university (Harvard T.H. Chan School of Public Health). LK is employed by a non-profit (Medic). PT is a graduate student at a public university (University of New South Wales). S. Saud is employed by a government hospital of Nepal (Civil Service Hospital). YKBK is employed by a government hospital of Nepal (COVID Hospital in Shikhar municipality). AB is employed by the local government of Nepal (Amargadhi municipality). R. Shrestha and KRM are employed by a non-profit hospital (Dhulikhel Hospital, Kathmandu University Hospital). R. Kafle is employed by a Nepal-based non-profit (Nick Simons Institute). GNS is a director of the Nursing and Social Security Division under the Government of Nepal Ministry of Health and Population. All authors declare that we have no competing financial interests., (Copyright: © 2023 Tiwari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

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., (© Nepal et al.)

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions., Competing Interests: Competing interests: PA, AA, NC, DC, BD, SD, BG, TG, SH, DJ, SKa, RM, SPa, MP, SPo, IR, AR, PR, AT and RT are employed by and AK, DS, BA, GD, SMa, SMe, RS, LW and DM work in partnership with, a non-profit healthcare company (Nyaya Health Nepal, with support from the USA-based non-profit, Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic and private foundation sources. AK is a medical student at and DC, SKi, SMa and DM are faculty members at a private medical school (Icahn School of Medicine at Mount Sinai). DS and RS are employed at an academic medical centre (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS and RS are faculty members at a private medical school (Harvard Medical School). DS is employed at an academic medical centre (Beth Israel Deaconess Medical Center) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS is employed at an academic research centre (Ariadne Labs) that is jointly supported by an academic medical centre (Brigham and Women’s Hospital) and a private university (Harvard TH Chan School of Public Health) via public sector research funding and private philanthropy. BA is a faculty member at a public university (University of California, San Francisco). DC is a faculty member at and DC and SH are employed part-time at a public university (University of Washington). GD, BG, SMe, PR and LW are fellows with a bidirectional fellowship programme (HEAL Initiative) that is affiliated with a public university (University of California, San Francisco) that receives funding from public, philanthropic and private foundation sources. GD is employed part-time at a public medical centre (Natividad Medical Center). MD and DJ are employed by the Government of Nepal (Ministry of Health and Population, Nepal Health Research Council and Department of Health Services, respectively). SKa is a graduate student at a private university (Eastern University). BKa and AS are employed at a private university (Kathmandu University). BKa is a faculty member at a public research university (Sun Yat-sen University). SKi is the founding executive director at an advocacy and leadership network (Young Professionals Chronic Disease Network) that receives funding from individual philanthropy. BKo is a faculty member at a public university (Tribhuvan University, Institute of Medicine). LK is a fellow at a public university (Virginia Commonwealth University) and is supported by a Hubert H Humphrey Fellowship from the US Department of State. SMa is a voting member on the Board of Directors with Group Care Global, a position for which she receives no compensation. SMe works in partnership with a public medical center on the border of a Native American reservation (Gallup Indian Medical Center) that is managed using public sector funding through the Indian Health Services. IN is a graduate student at and AS is a postdoctoral fellow at a private university (Harvard T H Chan School of Public Health). IN is a voting member on the Board of Directors with Possible, (a position which she joined after the conclusion of the research described in this manuscript), BP is a member on the Board of Advisors with Nyaya Health Nepal, and DM is a non-voting member on the Board of Directors with Possible, positions for which they receive no compensation. BP is employed at a private medical centre (Hospital for Advanced Medicine and Surgery) that receives revenue from fee-for-service transactions. RS is employed at an academic medical centre (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. PT is a graduate student at a public university (University of New South Wales). LW works in partnership with a medical center (Gallup Indian Medical Center) that receives revenue through fee-for-service medical transactions and private sector grants. All authors have read and understood BMJ Global Health’s policy on declaration of interests and declare that they have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.