Estimating country-level nutrition investments: Global implications of a two country study

: 1.005_FOS Old partners e who were they? Examining the factors that sustain global health partnerships J. James, S. Pak-Gorstein, R. Umoren; Indiana University-Purdue University, Indianapolis, IN, USA, University of Washington, Seattle, WA, USA Background: As academic institutions seek to integrate global health (GH) training into the education continuum, there is a growing recognition of the challenges to developing and sustaining a GH program. GH partnerships vary in focus, trainees, number, and type of partners. Little is known about the factors that sustain academic GH partnerships. Methods: From March to November 2013, we conducted a series of structured interviews to explore the relationship between a reciprocal and a successful GH program. The study was approved as IRB exempt by the Indiana University Institutional Review Board. After a review of published program descriptions to identify reciprocal elements based on the WEIGHT guidelines, seven GH programs were selected to participate. All programs were part of a University-affiliated Center or Institute for Global Health. Six programs were U.S.-based, with one U.K.-based program. GH Program length was 5-25 (14.8) years with 5-9 (7.3) partners in Africa, Asia, Central and South America. Qualitative data from the interview transcripts were independently reviewed by two study investigators (JJ, RU) experienced in thematic analysis using the constant comparative method. Saturation was achieved after no new themes emerged from the data. NVIVO 10 (QSR International) software was used to organize data and assess coder agreement. Findings: The themes that emerged around successful GH programs were: Attention to partnership development, often with a specific individual playing a key role as the “guardian of the mission”; “Identifying challenges”, collaboratively with partner input; “Role of learners”, in both developing and sustaining the program; a routine of ”Constant communication”; “Role of funding” and ”Evaluation of program impact”. Other themes were: the “Randomness of program development”, as programs responded to new needs and challenges; a “Constantly changing landscape”, with changes in institutional leadership and local needs; and the challenges of leadership: “So much administration”. Interpretation: Global health programs encounter many challenges that threaten their longevity. Attention to early partnership development with mutual goals, work with local ethics committees in conducting research, keeping open channels of communication between partners, utilizing multiple sources of funding, and active evaluation of program impact contribute to long-term sustainability.

Interpretation: Political economy analysis is a potentially productive approach to conducting a form of health systems research that privileges the role of social, political, and economic arrangements in the distribution of national and global disease burdens and one that interrogates the relations of power that sustain the status quo. Here I present an outline of a political economy analysis that is based in the traditions of political economy of health and social medicine. More work is needed to clarify this approach, as well as other approaches based in alternative traditions of political economy (i.e. neoclassical, neoliberal, institutional, etc.).

Funding: None.
Abstract #: 1.005_FOS Old partners e who were they? Examining the factors that sustain global health partnerships J. James 1 , S. Pak-Gorstein 2 , R. Umoren 2 ; 1 Indiana University-Purdue University, Indianapolis, IN, USA, 2 University of Washington, Seattle, WA, USA Background: As academic institutions seek to integrate global health (GH) training into the education continuum, there is a growing recognition of the challenges to developing and sustaining a GH program. GH partnerships vary in focus, trainees, number, and type of partners. Little is known about the factors that sustain academic GH partnerships.
Methods: From March to November 2013, we conducted a series of structured interviews to explore the relationship between a reciprocal and a successful GH program. The study was approved as IRB exempt by the Indiana University Institutional Review Board. After a review of published program descriptions to identify reciprocal elements based on the WEIGHT guidelines, seven GH programs were selected to participate. All programs were part of a University-affiliated Center or Institute for Global Health. Six programs were U.S.-based, with one U.K.-based program. GH Program length was 5-25 (14.8) years with 5-9 (7.3) partners in Africa, Asia, Central and South America. Qualitative data from the interview transcripts were independently reviewed by two study investigators (JJ, RU) experienced in thematic analysis using the constant comparative method. Saturation was achieved after no new themes emerged from the data. NVIVO 10 (QSR International) software was used to organize data and assess coder agreement.
Findings: The themes that emerged around successful GH programs were: Attention to partnership development, often with a specific individual playing a key role as the "guardian of the mission"; "Identifying challenges", collaboratively with partner input; "Role of learners", in both developing and sustaining the program; a routine of "Constant communication"; "Role of funding" and "Evaluation of program impact". Other themes were: the "Randomness of program development", as programs responded to new needs and challenges; a "Constantly changing landscape", with changes in institutional leadership and local needs; and the challenges of leadership: "So much administration".
Interpretation: Global health programs encounter many challenges that threaten their longevity. Attention to early partnership development with mutual goals, work with local ethics committees in conducting research, keeping open channels of communication between partners, utilizing multiple sources of funding, and active evaluation of program impact contribute to long-term sustainability.
Abstract #: 1.006_FOS Estimating country-level nutrition investments: Global implications of a two country study A. Pomeroy-Stevens 1 , A. D'Agostino 1 , M.B. Shrestha 2 , A. Muzoora 3 , N. Adero 3 , M. Shrestha 2 ; 1 John Snow Inc/SPRING Project, Arlington, VA, 2 HKI Nepal, Kathmandu, Nepal, 3 SPRING Uganda, Kampala, Uganda Background: Malnutrition is one of the greatest challenges to health and development in many low-and middle-income countries (LMIC). Like any national challenge, sufficient, sustained funding is needed to address this issue. Yet there is little information available in most LMIC on funding for nutrition. To meet the need for better data on nutrition financing, USAID's SPRING Project has collaborated with the governments of Uganda and Nepal to analyze funding for nutrition and to develop a series of tools that can be shared globally.
Methods: SPRING adapted the Scaling Up Nutrition (SUN) Movement's 3-Step approach to conduct a mixed method, country-specific analysis of multi-sector government budgets and donor reporting. SPRING defined the range of searchable nutrition activities across six sectors by using the country's national nutrition action plan (NNAP). Budgets and work plans were collected during key informant interviews with government, NGO and donor stakeholders, and analyzed against the NNAP activity matrices. Budget validation meetings were then held to ensure completeness, accuracy, and breakdown of integrated activities.
Findings: SPRING's validated estimates of two fiscal years (2013/ 14 and 2014/15) have been shared with country stakeholders and with SUN as part of their regional and global financial tracking exercises. By relying on nationally-recognized and locally-created documents, SPRING provided a familiar basis for discussions to increase credibility and local ownership of findings. Funding allocations for both countries can be provided by funding source, sector, and NNAP strategic area. Results of the analysis include that budgeted funds exceeded NNAP estimates of cost, but budgets were not always fully expended. The balance of domestic to donor funding varied widely by country. The highest sector contributors to nutrition were Health, Agriculture, and Local Government/Development.

Interpretation:
We need a more accurate global picture of nutrition funding. SPRING's validated country approach is a step toward that goal, and is now available in a nutrition budget analysis tool. SPRING is also collaborating with SUN and selected implementing partners to harmonize this with other financial tracking methods to provide a unified set of global guidelines on nutrition financial tracking.  Structure/Method/Design: MOHSW, Abbott Fund Tanzania, and Muhimbili National Hospital recognized from the beginning that while new infrastructure and equipment was necessary, only an innovative approach to human resource development and care delivery would allow the EMD to provide sustainable first-class emergency care to all Tanzanians. An Emergency Medicine specialty program school was established, in partnership with emergency medicine experts from UCSF and other universities. Abbott Fund also worked with the non-profit consulting firm FSG to develop a financial and professional sustainability strategy, based on the premise that public institutions can attract paying patients to subsidize the costs of all care by offering high quality, in-demand services.
Outcome & Evaluation: The EMD opened in January 2010, and became a business unit with the authority to manage its own finances in July 2013. By June 2015, the EMD was serving w130 patients per day, with 58% receiving subsidized or free care. The EMD generated 1 million USD of revenue from private and insured patients in its first year of revenue collection covering supply and operating expenses previously covered by donations. Patient volume and revenue growth has continued. The residency program has graduated 17 specialists and retained 12 as faculty, while other graduates have gone on to lead other Tanzanian emergency departments.
A recent study found a 5.4% drop in the hospital-wide mortality rate in the 2 years following the opening of the EMD.
Going Forward: The EMD's progress illustrates a compelling model for sustainably improving healthcare services in resource-constrained settings. Program Purpose: Planning is the foundation of any successful and sustainable project. Planning methods have long been used in developed countries in healthcare settings. As domestic healthcare programs extend their reach into global settings, making use of existing tools facilitates the planning processes needed in global settings; however, some adaptions made be necessary for cultural, logistical, political or other reasons. We are an academic healthcare organization with 20 years' experience in domestic planning tool development and implementation in a very successful U.S.-based pediatric hematology-oncology center. We reviewed and modified our standardly used program planning tools as they were applied in global health program planning initiatives in sub-Saharan African programs.
Structure/Method/Design: Over the course of planning four large healthcare programs in SSA, modifications to well-used planning tools included the need to address logistics of planning across great distances with communication challenges via a variety of technological approaches, relationship building over long distances with less face-to-face contact, and adaptation of communication approaches. Other modifications required the construct and implementation of unique technologies such as data gathering databases to catalogue large amounts of information rapidly during both offsite and onsite assessment stages. The ordinary processes, order and methods of the steps used for planning required more flexibility to fit the setting, culture and logistics. Examples included increasing the number of individual interviews with fewer group interviews. While the building blocks of a strong, sustainable plan were achieved, the format, presentation and delivery required adaptation.
Outcome & Evaluation: The output of the globally adapted planning process, a detailed, comprehensive assessment report document, successfully addressed the required elements of a solid strategic plan and received positive feedback from the participating parties. The approach taken to consider how to leverage and adapt the standard process, supported the development of a plan with a delivery method, that while different from the one used domestically, was better suited to the unique needs of the stakeholders in the global setting.
Going Forward: As these programs move forward, continued application, assessment and improvement of planning tools and training of more globally placed staff in their use will be the focus.