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The mental health burden of displaced communities is enormous and ever-increasing. Community-based Mental Health and Psychosocial Support (CB-MHPSS) interventions are seen as vital in addressing this challenge, and they have been lauded as being integral in the overall multi-level Mental Health and Psychosocial Support Intervention approach in humanitarian settings. This article assumes that CB-MHPSS innately require a participatory approach to truly benefit the targeted population. It explores important benefits and challenges of using a participatory approach with CB-MHPSS interventions, as well as identifying key considerations in their design and implementation. A literature review of the PubMed database, Web of Science, The Cochrane Library of Systematic Reviews, and defined 'grey literature' identified 42 relevant articles. Thematic analysis identified dilemmas raised by many of the authors, including: the disconnect between using a participatory community-based approach and evidence-based medicine; using locally derived versus standardised measures; incorporating local mental health expressions and idioms into the intervention versus using standardised diagnostic classifications; empowering communities versus falling into the hands of local power dynamics and agendas; and trying to allow for sufficient time to develop relationships and build trust with the targeted community. The findings can serve to encourage reflexivity and critical thinking in the design and implementation of future CB-MHPSS interventions, which will be required to develop robust evidence that supports CB-MHPSS interventions in displaced communities.

Primary health care (PHC) strengthening in order to achieve the Sustainable Development Goal has again, 40 years after the Alma-Ata declaration, been declared a priority by the global health community. Despite initial progress the Alma-Ata vision of Health for All by the year 2000 was not realised. In this analysis we (1) examine the challenges that comprehensive PHC faced after the Alma-Ata declaration, (2) provide an analysis of the current opportunities and threats to comprehensive PHC strengthening on the global, national and community level and (3) review the most important policy recommendations and related evidence to address these threats for success of the Astana declaration. Factors that are predominantly opportunities are the treasure of historical lessons from the past 40 years, the increased attention to social and environmental determinants of health, the global economic growth and new technologies, in particular digital medicine, which also have the potential to revolutionise community involvement. Factors that are currently predominantly threats are insecurity, conflicts and disease outbreaks; lack of sustained political commitment and inappropriate monitoring and evaluation structures; inappropriate and unsustainable financing models; insufficient health workforce recruitment, employment and retention; missing support of physicians and their professional organisations; inadequately addressing the needs of the community and not giving attention to gender equity. In contrast to the policy and evidence context in 1978 when Alma-Ata was passed there are today policy recommendations and a large body of evidence that can address the threats to comprehensive PHC-and turn them into opportunities.

Background and objectives: Diabetes has become an increasingly prevalent and severe public health problem in Nepal. The Nepalese health system is struggling to deliver comprehensive, quality treatment and services for diabetes at all levels of health care. This study aims to review evidence on the prevalence, cost and treatment of diabetes mellitus type 2 and its complications in Nepal and to critically assess the challenges to be addressed to contain the epidemic and its negative economic impact. Design: A comprehensive review of available evidence and data sources on prevalence, risk factors, cost, complications, treatment, and management of diabetes mellitus type 2 in Nepal was conducted through an online database search for articles published in English between January 2000 and November 2015. Additionally, we performed a manual search of articles and reference lists of published articles for additional references. Results: Diabetes mellitus type 2 is emerging as a major health care problem in Nepal, with rising prevalence and its complications especially in urban populations. Several challenges in diabetes management were identified, including high cost of treatment, limited health care facilities, and lack of disease awareness among patients. No specific guideline was identified for the prevention and treatment of diabetes in Nepal. Conclusions: We conclude that a comprehensive national effort is needed to stem the tide of the growing burden of diabetes mellitus type 2 and its complications in Nepal. The government should develop a comprehensive plan to tackle diabetes and other non-communicable diseases supported by appropriate health infrastructure and funding.

BACKGROUND AND OBJECTIVES: Diabetes has become an increasingly prevalent and severe public health problem in Nepal. The Nepalese health system is struggling to deliver comprehensive, quality treatment and services for diabetes at all levels of health care. This study aims to review evidence on the prevalence, cost and treatment of diabetes mellitus type 2 and its complications in Nepal and to critically assess the challenges to be addressed to contain the epidemic and its negative economic impact. DESIGN: A comprehensive review of available evidence and data sources on prevalence, risk factors, cost, complications, treatment, and management of diabetes mellitus type 2 in Nepal was conducted through an online database search for articles published in English between January 2000 and November 2015. Additionally, we performed a manual search of articles and reference lists of published articles for additional references. RESULTS: Diabetes mellitus type 2 is emerging as a major health care problem in Nepal, with rising prevalence and its complications especially in urban populations. Several challenges in diabetes management were identified, including high cost of treatment, limited health care facilities, and lack of disease awareness among patients. No specific guideline was identified for the prevention and treatment of diabetes in Nepal. CONCLUSIONS: We conclude that a comprehensive national effort is needed to stem the tide of the growing burden of diabetes mellitus type 2 and its complications in Nepal. The government should develop a comprehensive plan to tackle diabetes and other non-communicable diseases supported by appropriate health infrastructure and funding.

Strengthening Primary Health Care Systems is the most effective policy response in low-and middle-income countries to protect against health emergencies, achieve universal health coverage, and promote health and wellbeing. Despite the Astana declaration on primary health care, respective investment is still insufficient in Sub-Sahara Africa. The SARS-CoV-2019 pandemic is a reminder that non-communicable diseases (NCDs), which are increasingly prevalent in Sub-Sahara Africa, are closely interlinked to the burden of communicable diseases, exacerbating morbidity and mortality. Governments and donors should use the momentum created by the pandemic in a sustainable and effective way by pivoting health spending towards primary health care.

Strengthening Primary Health Care Systems is the most effective policy response in low-and middle-income countries to protect against health emergencies, achieve universal health coverage, and promote health and wellbeing. Despite the Astana declaration on primary health care, respective investment is still insufficient in Sub-Sahara Africa. The SARS-CoV-2019 pandemic is a reminder that non-communicable diseases (NCDs), which are increasingly prevalent in Sub-Sahara Africa, are closely interlinked to the burden of communicable diseases, exacerbating morbidity and mortality. Governments and donors should use the momentum created by the pandemic in a sustainable and effective way by pivoting health spending towards primary health care.

The health system in Nepal is characterized by a wide network of health facilities and community workers and volunteers. Nepal's Interim Constitution of 2007 addresses health as a fundamental right, stating that every citizen has the right to basic health services free of cost. But the reality is a far cry. Only 61.8% of the Nepalese households have access to health facilities within 30 min, with significant urban (85.9%) and rural (59%) discrepancy. Addressing barriers to health services needs urgent interventions at the population level. Recently (February 2015), the Government of Nepal formed a Social Health Security Development Committee as a legal framework to start implementing a social health security scheme (SHS) after the National Health Insurance Policy came out in 2013. The program has aimed to increase the access of health services to the poor and the marginalized, and people in hard to reach areas of the country, though challenges remain with financing. Several aspects should be considered in design, learning from earlier community-based health insurance schemes that suffered from low enrollment and retention of members as well as from a pro-rich bias. Mechanisms should be built for monitoring unfair pricing and unaffordable copayments, and an overall benefit package be crafted to include coverage of major health services including non-communicable diseases. Regulations should include such issues as accreditation mechanisms for private providers. Health system strengthening should move along with the roll-out of SHS. Improving the efficiency of hospital, motivating the health workers, and using appropriate technology can improve the quality of health services. Also, as currently a constitution drafting is being finalized, careful planning and deliberation is necessary about what insurance structure may suit the proposed future federal structure in Nepal.

BACKGROUND: In the backdroup of a rapidly increasing burden of diabetes in Nepal, a community-based diabetes management program is implemented involving female community health volunteers (FCHVs) under the government run FCHVs program. FCHVs received an intensive one-week training workshop on prevention, control and management of diabetes. The training program was implemented and evaluated to enhance diabetes knowledge of FCHVs and matched according to their literacy level. METHODS: A range of teaching methods were applied, including desk review, active participation, lectures, presentations, discussions, role plays, demonstration and field test. Evaluation of the knowledge attained was done by testing before and after the workshop. Major milestones in the development of the training module were presented from desk review and ending in stakeholder's participation in reviewing and revising the training package. The qualitative interview transcripts of FCHVs were analyzed thematically. RESULTS: A 5-day training package was developed through a desk review of interventions using community health workers (CHWs) on diabetes management from similar settings. Training module included home-based blood glucose monitoring and home-based health education on life style counselling delivered through a participatory learning approach. There were 20 participants with a mean age of 47 years (SD ± 5.7). The overall assessment of knowledge of diabetes before-after the training, evaluated by the Diabetes Knowledge Questionnaire (DKQ) showed increases in mean score from 40.4% before training to a mean score of 63.3% after training (Paired t-test: t = - 11.1, P < 0.001, and Wilcoxon test for paired samples: z = - 3.930, P = 0.0001). Focus group discussions (FGDs) revealed that FCHVs had a favorable perception of the training program's effectiveness. CONCLUSIONS: If FCHVs are appropriately trained they may be instrumental in providing counseling and screening for diabetes management in their communities.

Background: The greatest risk factor for cardiovascular disease is hypertension, which can be alleviated via diet, exercise, and adherence to medication. Yet, blood pressure control in Nepal is inadequate, which is partly hindered by a lack of evidence-based, low-cost, scalable, and cost-effective cardiovascular disease prevention programmes. The the community-based management of hypertension in Nepal (COBIN) study was a 12-month community-based hypertension management programme of blood pressure monitoring and lifestyle counselling intervention undertaken by female community health volunteers (FCHVs) in Nepal, against usual care, which showed success in reducing blood pressure. Here we aimed to retrospectively quantify the budget impact and cost-effectiveness of the scale-up of the programme. Methods: In this retrospective analysis, we collected participant-level data from the COBIN study; programme delivery cost data from programme administrators from the COBIN study group; and popualtion and other data from WHO, the World Bank, and the Nepalese Government. We estimated costs per participant and total costs of a national scale-up of the COBIN programme focusing on two scenarios: scenario A, delivery of the intervention to only people aged 25–65 years with hypertension; and scenario B, delivery of the intervention to all adults aged 25–65 years regardless of hypertension status. Effectiveness was based on in-trial blood pressure reductions converted to cardiovascular disease disability-adjusted life-years (DALYs) averted. The primary cost-effectiveness measure was incremental cost per averted cardiovascular disease DALY (calculated using the incremental cost-effectiveness ratio [ICER]) from a health system perspective, including programme delivery and incremental medication costs. We did univariate sensitivity analyses of scenario B to assess the effect of uncertainty in key parameter values in our calculations. Findings: From a health system perspective, the first-year budget impact was US$7·1 million in scenario A and $10·8 million in scenario B. With each subsequent year, the costs decreased by approximately 50%. In the base-case cost-effectiveness analysis, from the health system perspective, scenario A resulted in an ICER of $582 per DALY averted and scenario B resulted in an ICER of $411 per DALY averted. The ICER was most sensitive to uncertainty in the number of total avertable cardiovascular disease DALYs in the eligible population. Interpretation: The programme is projected to be highly cost-effective in both scenarios compared with the WHO thresholds for cost-effectiveness for Nepal. For policy makers intending to meet the UN Sustainable Development Goal of reducing premature mortality from non-communicible diseases, this intervention should be considered. Funding: Duke-NUS Medical School, Singapore.

BACKGROUND: The greatest risk factor for cardiovascular disease is hypertension, which can be alleviated via diet, exercise, and adherence to medication. Yet, blood pressure control in Nepal is inadequate, which is partly hindered by a lack of evidence-based, low-cost, scalable, and cost-effective cardiovascular disease prevention programmes. The the community-based management of hypertension in Nepal (COBIN) study was a 12-month community-based hypertension management programme of blood pressure monitoring and lifestyle counselling intervention undertaken by female community health volunteers (FCHVs) in Nepal, against usual care, which showed success in reducing blood pressure. Here we aimed to retrospectively quantify the budget impact and cost-effectiveness of the scale-up of the programme. METHODS: In this retrospective analysis, we collected participant-level data from the COBIN study; programme delivery cost data from programme administrators from the COBIN study group; and popualtion and other data from WHO, the World Bank, and the Nepalese Government. We estimated costs per participant and total costs of a national scale-up of the COBIN programme focusing on two scenarios: scenario A, delivery of the intervention to only people aged 25-65 years with hypertension; and scenario B, delivery of the intervention to all adults aged 25-65 years regardless of hypertension status. Effectiveness was based on in-trial blood pressure reductions converted to cardiovascular disease disability-adjusted life-years (DALYs) averted. The primary cost-effectiveness measure was incremental cost per averted cardiovascular disease DALY (calculated using the incremental cost-effectiveness ratio [ICER]) from a health system perspective, including programme delivery and incremental medication costs. We did univariate sensitivity analyses of scenario B to assess the effect of uncertainty in key parameter values in our calculations. FINDINGS: From a health system perspective, the first-year budget impact was US$7·1 million in ...

The World Health Organization recommends salt reduction as a cost‐effective intervention to prevent noncommunicable diseases. Salt‐reduction interventions are best tailored to the local context, taking into consideration the varying baseline salt‐intake levels, population's knowledge, attitude, and behaviors. Fundamental to reduction programs is the source of dietary salt‐intake. In South Asian countries, there is a paucity of such baseline evidence around factors that contribute to community salt intake. Upon reviewing the electronic literature databases and government websites through March 31, 2021, we summarized dietary salt intake levels and aimed to identify major sources of sodium in the diet. Information on the current salt reduction strategies in eight South Asian countries were summarized, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. One hundred twelve publications (out of identified 640) met our inclusion‐exclusion criteria for full text review. Twenty‐one studies were included in the review. Quality of the included studies was assessed using the US National Heart, Lung, and Blood Institute assessment tool. The primary result revealed that mean salt intake of South Asian countries was approximately twice (10 g/day) compared to WHO recommended intake (< 5 g/day). The significant proportion of salt intake is derived from salt additions during cooking and/or discretionary use at table. In most South Asian countries, there is limited data on population sodium intake based on 24‐h urinary methods and sources of dietary salt in diet. While salt reduction initiatives have been proposed in these countries, they are yet to be fully implemented and evaluated. Proven salt reduction strategies in high‐income countries could possibly be replicated in South Asian countries; however, further community‐health promotion studies are necessary to test the effectiveness and scalability of those strategies in the local context.

The World Health Organization recommends salt reduction as a cost-effective intervention to prevent noncommunicable diseases. Salt-reduction interventions are best tailored to the local context, taking into consideration the varying baseline salt-intake levels, population's knowledge, attitude, and behaviors. Fundamental to reduction programs is the source of dietary salt-intake. In South Asian countries, there is a paucity of such baseline evidence around factors that contribute to community salt intake. Upon reviewing the electronic literature databases and government websites through March 31, 2021, we summarized dietary salt intake levels and aimed to identify major sources of sodium in the diet. Information on the current salt reduction strategies in eight South Asian countries were summarized, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. One hundred twelve publications (out of identified 640) met our inclusion-exclusion criteria for full text review. Twenty-one studies were included in the review. Quality of the included studies was assessed using the US National Heart, Lung, and Blood Institute assessment tool. The primary result revealed that mean salt intake of South Asian countries was approximately twice (10 g/day) compared to WHO recommended intake (< 5 g/day). The significant proportion of salt intake is derived from salt additions during cooking and/or discretionary use at table. In most South Asian countries, there is limited data on population sodium intake based on 24-h urinary methods and sources of dietary salt in diet. While salt reduction initiatives have been proposed in these countries, they are yet to be fully implemented and evaluated. Proven salt reduction strategies in high-income countries could possibly be replicated in South Asian countries; however, further community-health promotion studies are necessary to test the effectiveness and scalability of those strategies in the local context.

Primary Health Care (PHC) is the backbone of health systems and a cornerstone of Universal Health Coverage. In 2018, political commitment to PHC, including a comprehensive approach based on essential care throughout the lifespan, integrated public health functions, and community empowerment was reaffirmed by international stakeholders in Astana. As recent events exposed weaknesses of health care systems worldwide, growing attention has been paid to strengthening PHC. While the role of care providers as health advocates has been recognized, they may lack skills, opportunities, and resources to actively engage in advocacy. Particularly for PHC providers, guidance and tools on how to advocate to strengthen PHC are scarce. In this article, we review priority policy areas for PHC strengthening with relevance for several settings and health care systems and propose approaches to empower PHC providers—physician, non-physician, or informal PHC providers—to advocate for strengthening PHC in their countries by individual or collective action. We provide initial ideas for a stepwise advocacy strategy and recommendations for practical advocacy activities. Our aim is to initiate further discussion on how to strengthen health care provider driven advocacy for PHC and to encourage advocates in the field to reflect on their opportunities for local, national, and global action.

Primary Health Care (PHC) is the backbone of health systems and a cornerstone of Universal Health Coverage. In 2018, political commitment to PHC, including a comprehensive approach based on essential care throughout the lifespan, integrated public health functions, and community empowerment was reaffirmed by international stakeholders in Astana. As recent events exposed weaknesses of health care systems worldwide, growing attention has been paid to strengthening PHC. While the role of care providers as health advocates has been recognized, they may lack skills, opportunities, and resources to actively engage in advocacy. Particularly for PHC providers, guidance and tools on how to advocate to strengthen PHC are scarce. In this article, we review priority policy areas for PHC strengthening with relevance for several settings and health care systems and propose approaches to empower PHC providers-physician, non-physician, or informal PHC providers-to advocate for strengthening PHC in their countries by individual or collective action. We provide initial ideas for a stepwise advocacy strategy and recommendations for practical advocacy activities. Our aim is to initiate further discussion on how to strengthen health care provider driven advocacy for PHC and to encourage advocates in the field to reflect on their opportunities for local, national, and global action.