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Good Health

READ THE STORIES: Improving Health through Evidence-based Local Solutions Around the World | Improving Health Systems Resilience | Strengthening Policies and Programs to Improve Health Outcomes in the U.S. | Responding to Emerging Malaria Risks

Improving Health through Evidence-based Local Solutions Around the World

Tailoring Local Solutions to Control the HIV Epidemic in Mozambique

It was, Paula Manual thought, a routine antenatal appointment at a local clinic. It wasn’t. The 27-year-old mother of two emerged with an unexpected diagnosis: HIV positive. The community sprang into action to help.

After the visit, the clinic assigned her a “mentor mother,” who coached Paula through the emotional process of disclosing her diagnosis to her husband, Armando. A community health worker and lay counselor together visited the couple at their home, testing Armando and their two children. Armando tested positive, while the two children were negative. That was not the end of it. “When I took the HIV test, the mentor mother gave me all the support so that I could continue with the treatment and actively participate in the prenatal consultations,” said Armando, who is taking antiretroviral therapy (ART). “Because of that, my wife and I had a healthy baby.”

Credit the Christian Council of Mozambique (CCM), a community-based organization in Sofala province that deploys community health workers to link patients and health facilities, even bringing services directly to families when the need arises. CCM’s partnerships with health facilities ensure high-quality and empathetic counseling and clinical care. During Paula’s pregnancy, the family received frequent visits from their mentor mother, who offered consultative and emotional support to both Paula and Armando. Once their son was born, the couple administered medicine to their newborn and brought him to at-risk child consultations.

CCM can provide these crucial services thanks to technical and financial support from the Abt-led USAID Efficiencies for Clinical HIV Outcomes (ECHO) project, which began in 2019 when many of those living with HIV were abandoning treatment and identifying them was a challenge. ECHO supports basic care and treatment for people living with HIV and strengthens community capacity for outreach, treatment, and counseling.

This collaboration shows how community-level localization works. ECHO partners directly with CCM and other community-based organizations to train and deploy mentor mothers and community health workers. We also support these organizations on administrative functions—from budgeting to human resources activities to prepare for eventual direct donor funding.

The results were remarkable as treatment drop-outs and mother-to-child transmission rates declined precipitously from 2019 to 2022. In Sofala, where CCM operates, patient drop-outs plummeted from 15 percent to 1.4 percent of Sofala’s active patients per quarter. Across ECHO-supported provinces, we saw these quarterly numbers fall from 15 percent to just 1.7 percent. Positivity rates for at-risk children whose mothers were diagnosed with HIV dropped by nearly 50 percent, from 5 percent to 2.6 percent.

At the community level, ECHO empowers health workers to test eligible members of their community, engage in follow-up to ensure that at-risk patients start and maintain treatment, and connect with their family members and sexual partners to offer them testing services. The strategies require an immense level of trust, and community-based organizations are well placed for this work.

ECHO isn’t working only with community organizations in its localization approach. It also collaborates with local government entities trying to control the HIV epidemic, such as the Provincial Health Directorates (DPS), Provincial Health Services (SPS), and the Ministry of Health (MOH). ECHO’s collaboration with the SPS, notably, is evolving towards local self-sufficiency. The project has transitioned from providing simple in-kind grants to these local health departments to standard grants, which come with robust procurement, financial management, and technical support that is embedded directly in SPS offices and offers a path toward greater stability and autonomy.

ECHO also worked with the MOH to implement differentiated service delivery models, a recognition that patients in different situations need different care. The models include intensive and non-intensive models. Intensive models require monthly visits to health facilities while non-intensive models allow patients with stable health conditions to visit facilities less often.

A key change was expansion of three- and six-month drug distribution and community-based distribution. The COVID-19 threat and concerns about crowded health facilities prompted a change in the requirement that limited ART prescriptions to one month of medicine. Many patients simply couldn’t get to distant facilities monthly. When the MOH considered expanding a policy to allow more patients to get three months of prescriptions at once, ECHO provided crucial clinical evidence that supported the case for expanding the popular policy. Years later, the MOH is now transitioning patients to six-month distribution after seeing the model’s great success.

The results were dramatic. Enrollment in the six-month program in Tete skyrocketed from 172 to 17,112 in about eight months. A six-month supply led to an 83 percent decline in unnecessary clinic visits, a reduction in overcrowding at facilities, and a lightening of the load for overworked staff.

More importantly, after just a few months of offering differentiated services, ART adherence shot up and the number of treatment dropouts plummeted to record lows. In early 2020, for example, three-month retention was just 78 percent in Tete province and 70 percent in Niassa. By July 2022, that figure shot up to 99 percent in Tete and 96 percent in Niassa. Both provinces also saw steep drops in patients leaving treatment. In a single quarter, the number plunged 94 percent, from 10,210 to 632, in Tete, and 70 percent, from 2,175 to 648, in Niassa.

More patients staying on treatment means more people living productive and healthy lives with a greatly reduced chance of passing HIV to others. All of this shows the strengthened capacity of Mozambique’s national and provincial government entities and community-based institutions and workers to lead efforts to stem the spread of HIV.

LEARN MORE: Controlling the HIV Epidemic in Mozambique | Caught Between HIV+ and Climate Change: Mozambique’s Cyclone Victims Maintain Treatment Through Community Support
PROJECT: Efficiencies for Clinical HIV Outcomes
CLIENT: U.S. Agency for International Development (USAID)

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Engaging Community Leaders to Improve Health in Tajikistan

On any given Friday, the Mosques of Bokhtar zone of Tajikistan’s Khatlon Region welcome over 65,000 men for prayers. Afterwards, the Senior Imams, like Usmonali Nurov, set aside 20 minutes to talk with male congregants about maternal, newborn, and child health (MNCH) as well as gender equity.

Local traditions don’t make it easy for men to speak about these important issues, which have been generally left to women. However, religious leaders like Imam Usmonali are making considerable inroads, breaking taboos by using Friday prayers to address them. “Well-formed male involvement approaches have significant potential to generate positive changes in mindsets and behavior of men according to religion,” he said.

The Abt-led USAID Healthy Mother, Healthy Baby (HMHB) Activity works with the religious leaders and religious activists to make this happen—supporting HMHB’s broader goals of working in partnership with the Ministry of Health and Social Protection of the Population to improve health and nutrition outcomes for women and children. The religious connection is key in prevailingly Tajik Muslim society. Religious leaders and their mosques play an influential role in reaching communities, especially those in remote areas where access to broadcast media is limited.

Since 2022, HMHB has trained over 300 male religious leaders—influential local men from 12 target districts—on MNCH, gender-sensitive and gender-based issues, including supporting the care of pregnant and lactating women.

HMHB and local Imams partner with the District Religious Committees to organize events during Friday prayers and call on men to enhance MNCH, explore gender-sensitive topics, and prevent domestic violence. Our project team conducted training on gender, equality, and social inclusion in eight Khatlon districts. They trained 526 facilitators, who afterward engaged in relevant awareness raising for village populations through community health teams.

HMHB collaborated with the Committee of Religion, Regulation of Traditions, Celebrations, and Ceremonies under the Government of the Republic of Tajikistan to develop the guidelines for Imams and religious leaders based on Khutba. This formal occasion for public preaching in the Islamic tradition is designed to explore knowledge of and attitudes and behaviors toward MNCH topics and to deepen men’s involvement and support. To reinforce knowledge and further open dialogue with men, HMHB printed 5,000 religious journals spotlighting key messages on improving nutritional status, gender, and family engagement. The messages and journals reached over 500,000 men in all 429 officially registered mosques.

HMHB has also helped build the Committee of Religion, Regulation of Traditions, Celebrations, and Ceremonies website and develop a package of informational materials. The collaboration will be ongoing. “For the first time, religious leaders had a chance to learn more and gained new knowledge on gender equality and the role of women and men in family and community. Religious leaders outlined their commitment and interest in raising such an important topic in daily prayer time, Nikah ceremonies (marriage ceremonies), and social events within the community,” said National Religious Committee spokesperson Afshin Muqimi. “We are sure that the process of this support will have a beneficial effect on behavioral changes of our Tajik community."

With this support, trained religious members like Imam Usmonali became a conduit for awareness and advocacy for women and equity among healthcare providers, families, and communities. “The believers who show the most perfect faith are those who have the best behavior, and the best of you are those who do the best to their wives,” Imam Usmonali recited on a recent Friday.

He speaks about the health and rights of girls and women and their respected status in the context of Islam. Congregants listen to his words closely. After prayers, smaller groups of men gather. The conversations continue. In Khatlon, the responsibility to speak and support the health, nutrition, and rights of women and girls is now shifting to include men.

LEARN MORE: Improving Nutrition for Tajik Mothers and Children
PROJECT: USAID Healthy Mother, Healthy Baby (HMHB) Activity
CLIENT: U.S. Agency for International Development (USAID)

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Strengthening Local Health Systems in Nepal

When USAID Nepal awarded USAID’s Strengthening Systems for Better Health Activity to an Abt-led consortium in 2018, it could not have come at a better time. Nepal’s shift away from centralized administrative and political structures to a federal system was gaining momentum. We embraced localization, partnering with provincial and municipal governments to help strengthen the capacity and systems they needed to deliver equitable and quality maternal, newborn, and child health (MNCH) and family planning services. With equity at the forefront, we focused on some of the most disadvantaged and remote communities. We strengthened data-driven planning, implementation, and monitoring of health interventions to advance equitable and accountable health-system governance.  

The results are promising. Improvements in safe delivery and newborn care have been significant. In the districts where we work, institutional deliveries jumped from 76 percent in 2017 to 93 percent in 2022. In the same period, the percentage of pregnant people who received the four antenatal checkups that protocols recommend rose from 56 percent to 73 percent. The percentage of deliveries attended by skilled health service providers increased from 65 to 84 percent.  

Our local teams provided tailored technical assistance to 138 municipalities. We helped local actors develop progressive health policies and undertake annual health planning, budgeting, and budget execution that routinely incorporated community input on service availability and quality. We worked with government partners to train local players to generate and use accurate, on-time health data and ensure a steady supply of essential medicines. We also helped them give health service providers, including private sector providers, the clinical skills, tools, and support needed to deliver quality services. Our capacity assessments—to measure municipal level capacities to manage the health system—have shown an overall improvement in these critical domains since the project started. The overall capacity score increased from 46 percent in 2018 to 82 percent in 2022. And it continues to improve.

Since 2018, we strengthened the capacity of over 600 health facilities to offer an appropriate range of high-quality, client-centered health services, particularly in MNCH and family planning. We supported training for 945 health workers on integrated management of neonatal and childhood illnesses, 568 health workers on family planning, and 336 skilled birth attendants. Just last year, over 3,200 heath workers in over 500 health facilities received coaching and mentoring in clinical and information systems priorities. 

As a result, new local governments are better able to meet the needs of their local constituents for basic MNCH and family planning services. Service use has increased, and more women and their families are accessing potentially life-saving interventions such as safe delivery and essential newborn care. Progress to date shows that the health system is adapting successfully to federalism. 

LEARN MORE: USAID's Strengthening Systems for Better Health in Nepal
PROJECT: USAID’s Strengthening Systems for Better Health Activity
CLIENT: U.S. Agency for International Development (USAID)

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Improving Health Systems Resilience

Expanding Access to Services through Telemedicine in Ukraine

Dr. V., a surgeon in Ukraine, vividly remembers the day the call came from a colleague in another city. A patient had arrived with gallstones and urgently needed surgery. But no one at the hospital had the required expertise. Could Dr. V. help? 

“There was no time for me to make a trip to the hospital the patient was at,” he recalls. “I decided to use [the] recently installed telemedicine platform. I was able to join the surgery in real time, see the issue, and assist my colleague in conducting the surgery remotely.” 

Increased use of telemedicine was global during COVID-19 lockdowns; for Ukraine, the Russian invasion in early 2022 made its use imperative and urgent. As of March 2023, more than 1,151 health facilities had been damaged or destroyed, according to Ukraine’s Ministry of Health.  

Aggravating matters, thousands of health providers—often the most highly trained—had become internally displaced or fled the country. The fighting discouraged Ukrainians from traveling from rural areas to larger cities to seek medical help. And a new category of patients has arisen amid the war—what Dr. V. described as “complex cases with explosion and burn injuries.”

Amid this crisis, telemedicine has become an essential tool for connecting people to health care. Digital technologies enable doctors to meet remotely with patients, view medical imaging results on a screen, and consult via video conference with specialists located elsewhere. That means many Ukrainians continue to receive high-quality care despite the constraints of combat. 

Foreign companies eager to assist the country donated much of the telemedicine equipment and licenses to Ukraine’s Ministry of Health. The USAID-funded and Abt-led Local Health System Sustainability Project (LHSS) helped the ministry create a standardized process to safely deploy appropriate technologies after systematically selecting, assessing, and testing them. 

Sustainably and systematically increasing use of telemedicine can strengthen the health system. To achieve that goal, LHSS supported the Ministry of Health in creating the country’s first interagency working group focused on developing and expanding access to telemedicine. LHSS collaborated with the working group to analyze the status of telemedicine implementation in Ukraine; develop recommendations on organizational and technical solutions for telemedicine implementation; and convene state authorities to agree on priorities and improve policies on telemedicine development.  

LHSS provided a structure to organize, govern, and channel private sector engagement and foster the expansion of access to quality care through telemedicine. The formation of the interagency working group was a major development in making healthcare services more accessible to the people of Ukraine. 

To ensure appropriate telemedicine use, Abt holds training sessions and provides 24/7 technical support for patients and health providers using the technologies. As of March 2023, LHSS had supported training for more than 1,000 medical workers in nearly 300 health facilities, resulting in more than 3,000 sessions with patients.  

One of the telemedicine solutions was the remote surgery tool Dr. V. used. Advanced cameras, monitors, software, and a secure network enable an off-site specialist to watch a live surgery in progress, see the patient’s vital signs, and provide direction to the surgeons in the operating room.

Dr. V. was skeptical of the equipment at first, thinking that mastering a new technology would be time-consuming and overwhelming. But he changed his mind once he began using it to save the lives of patients he’d never even seen or touched. 

Patients also are accepting this new way of receiving care. “It has become extremely inconvenient and often unsafe to go to medical appointments since the full-scale Russian invasion of Ukraine,” said a pregnant patient who used remote fetal monitoring at a district hospital to connect with an obstetrician. “To minimize the security risks, my obstetrician gave me an electronic device through which I can get examined from my home. The device connects to my smartphone, and once the examination is completed, the results are sent directly to my doctor’s phone.” 

The patient added, “I was hesitant at first, because I did not quite understand how one can get examined from home. But after the first remote examination, I realized how safe and convenient this is.” 

Together with the Ministry of Health, Abt's work has provided the Ukrainian people with a safe and reliable way to receive critical health care. Over the coming year, Abt will gradually transfer the job of supporting use of the donated telemedicine solutions to a local entity. By supporting this localization, Abt aims to ensure sustainability for Ukraine’s telemedicine program throughout the war—and in the post-war period that will follow. 

To avoid jeopardizing the safety and security of the health provider and patient interviewed for this article, their names and locations have not been disclosed.

Reinforcing Resilience through Private Sector Engagement in Jamaica

The Government of Jamaica didn’t have enough health workers to manage a rapid rollout of COVID-19 vaccines last year. So, the government decided to collaborate with the private sector, an initiative that could help address urgent needs and also establish sustainable long-term partnerships. But this was complex terrain. The USAID-funded and Abt-led Local Health System Sustainability Project (LHSS) helped facilitate the partnership, bolstering health sector resiliency for the future. 

Abt used our LHSS grant-making authority to provide $556,000 in grants to pharmacies, faith-based health organizations, private medical practices, and a private health care network. Between March and May 2022, these trusted providers delivered more than 9,000 COVID-19 vaccinations to their clientele. They included many people in underserved communities who likely would not otherwise have gotten vaccinated due to poor access and hesitancy fueled by misinformation.  

In the process, LHSS provided the grantees individually tailored capacity-strengthening support on such topics as cold chain management, marketing and communications, administrative procedures, and reporting mechanisms. The grants did just what they were supposed to do. They engendered mutual confidence and trust between the Jamaican Ministry of Health and Wellness and the private health sector. And they equipped the grantees with the know-how to support the government in future large-scale vaccination efforts and delivery of other important health services. “LHSS allowed me to think in the long term—where I wanted my company to go and what I need to do to get it there,” said Dr. Alex Tracey, the founder of a growing company, Online Medics, the first mobile app in Jamaica to provide virtual medical care for patients.   

Abt knows well that Jamaica is not an anomaly. Other resource-strapped public health systems can join forces with the private sector to expand access to medical care. It’s good for business and good for a nation’s health. 

LEARN MORE: Local Health System Sustainability Project
PROJECT: Local Health System Sustainability Project
CLIENT: U.S. Agency for International Development (USAID)

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Strengthening Policies and Programs to Improve Health Outcomes in the U.S.

Prioritizing Maternal and Child Health in the U.S.

Eighty-eight years ago, U.S. President Franklin D. Roosevelt established an agency to address the worsening health of mothers and babies during the Great Depression. Today, the Maternal and Child Health Bureau (MCHB), part of the U.S. Health Resources and Services Administration (HRSA), is the oldest part of the nation’s public health system—and a sprawling one. Its fiscal year 2024 proposed budget is just under $16 billion, and its patchwork of mandates, added to through various legislation over the decades, ranges from perinatal health to capacity building in quality assurance.

Now under an executive order, MCHB is taking a step back to reimagine its vision and develop a streamlined strategic plan for the next decade to strengthen the health of mothers, children, and families. The need is great. The maternal mortality rate jumped from 17.4 per 100,000 births in 2018 to 23.8 in 2020. Maternal mortality is three times worse for Black women than white women. The infant mortality rate is the worst of our economic peers, more than double the rate of Portugal and Spain. Black infant mortality is more than double that of white infants.

Equity underlies MCHB’s objectives as this venerable agency overhauls bureaucracy and pursues a digital transformation to make it more efficient. And as part of its ambitious 10-year strategic plan, the agency tasked Abt with helping craft these new goals and objectives.

Abt engaged with interested parties in focus groups and interviews, gathering input from people who focus on maternal and child health and those who serve disenfranchised communities, including people with lived experience. We brought perspectives from working with other agencies grappling with maternal and health issues. For example, after scanning federal agencies working on those topics, we created a matrix that showed where MCHB could encourage collaborative partnerships, such as the National Institutes of Health, Administration for Children and Families, and Centers for Disease Control and Prevention.

The resulting plan, released in 2022, helps position MCHB to be a leader in addressing maternal and child health, including initiatives like the White House Blueprint for Addressing the Maternal Health Crisis.

Among other things, we conducted an organization assessment to determine readiness to implement the strategic plan and recommend transformations MCHB needs to meet the new goals. With different offices operating from different legislative authority, MCHB needed to align programs with collective objectives. The underlying expectation is ambitious: make real change for the more than 60 million people MCHB supports. The goals:

  • Assure access to high-quality and equitable health services to optimize health and well-being for all MCH populations
  • Achieve health equity for MCH populations
  • Strengthen public health capacity and the workforce for MCH
  • Maximize impact through leadership, partnership, and stewardship.

MCHB names equity as a goal in and of itself, an issue that interested parties were adamant about. “Public agencies have responsibility for programs and related inequalities,” said one interviewee. “There is an untapped opportunity at this time of an historical reckoning on racism in practices and policies. MCHB should become more anti-racist.” Added another: “We must center equity in our work.”

Interested parties also called for more and better data. “There is a need for more data capacity—better data, analysis, and use,” said one. “We (need more) racial/ethnic specific data overall and from programs. These data are critical in tackling equity.” But other focus group members noted that much of what MCHB does is hard to measure because it’s qualitative not quantitative. It’s “important to remember the adage: Not everything measured is worthwhile,” said one focus group member. “Not everything worthwhile can be measured.”

MCHB and Abt will continue collaborating on ways to come up with meaningful metrics. Data will be one way, but not the only one, to show that the new strategy is working for equitable improvement in the health of mothers, children, and families.

Abt looks forward to supporting MCHB as it transforms to realize its ambitious new vision.

LEARN MORE: Updating the Maternal and Child Health Bureau’s Strategic Plan
PROJECT: The MCHB Strategic Planning, Implementation and Organizational Transformation Contract
CLIENT: U.S. Department of Health and Human Services, Health Services and Resources Administration, Maternal and Child Health Bureau

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Improving Child Nutrition in the U.S.

How do kids in the U.S. who get subsidized school lunches fare in the summer when school’s out? Not well. Except for some who were part of a decade-long Food and Nutrition Service pilot grant program, the Summer Electronic Benefit Transfer (Summer EBT) program.

Families in 10 diverse states and three Tribal Organizations received support in the summer from the U.S. Department of Agriculture Food and Nutrition Service to buy the same kind of groceries approved for the Supplemental Nutrition Assistance Program (SNAP) and the Women, Infants, and Children (WIC) programs. “Fruits and vegetables aren’t cheap,” notes one Summer EBT parent, and the benefit “allowed us to have better quality food.”

The results were clear: A $60 monthly benefit reduced the most severe category of food insecurity by a third compared with those who received no funds. The benefit also meant more nutritious eating—with children in the program consuming 12 percent more fruits and vegetables and 23 percent more whole grains than those not in the program.

How do we know? Abt’s decade of evaluations. We assessed the benefits and examined approaches that worked in different contexts for families, retailers, and grantees. The findings paved the way for Congress to pass a bipartisan bill in December 2022 that created a permanent nationwide program for more than 29 million families. That’s impact.

States, Tribal Organizations, and Territories will start to roll out their Summer EBT programs in 2024, and the knowledge we accumulated provides a playbook for how to do it. We generated insights that states can consider implementing, plus an intuitive, interactive digital dashboard to help officials understand granular program use and trends. It includes information from grantees who know local needs, thus enabling customized solutions.

Top recommendations:

  • Allow for flexible food choices. If electricity is unreliable, for example, consumers can’t buy food that requires refrigeration. This can require training retailers.
  • Use spatial analysis and mapping data. States, Tribal Organizations, and Territories need to know where eligible households live, how far they have to travel to shop at a participating store, and whether transportation is available. They may need to enlist more retailers.
  • Decide which communication tactics will increase use of benefits: outreach via text messages or mobile apps; an online shopping app; or using schools to send out information.
  • Monitor redemption rates. To boost redemption rates, text benefit balances twice a month and send other texts weekly. Buying is higher after texts.

The evaluations showed that Summer EBT is beneficial—and the way forward for States, Tribal Organizations, and Territories. In the future, millions of children nationwide will be well served, both figuratively and literally.

LEARN MORE: Evaluating Summer Nutrition Assistance for Children
PROJECT: Evaluation of 2019–2022 Summer Electronic Benefits Transfer (EBT) Program
CLIENT: U.S. Department of Agriculture, Food and Nutrition Service

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Strengthening Responses to Mental Health Crises in the U.S.

Someone to talk to, someone to respond, and a safe place to go. The Substance Abuse and Mental Health Services Administration in the U.S. has established these three components as essential for a fully developed crisis response system. When states ensure access to local crisis call centers, mobile intervention services, and short-term receiving and stabilization centers, people in crisis can get the evidence-based care they need at the right time and in their community. Meeting people where they are can reduce avoidable emergency department visits, law enforcement involvement, and preventable tragedies.  

With recent catalysts including the COVID-19 pandemic and increases in suicide and drug overdose rates, U.S. federal and state agencies are allocating more resources to behavioral health crisis services than ever before. The Massachusetts Executive Office of Health and Human Services (EOHHS) received a grant from the Centers for Medicare and Medicaid Services. Abt and our partners, Advocates for Human Potential and Behavioral Health Network, helped the agency develop training materials for the mobile crisis intervention (MCI) workforce at the state’s 25 Community Behavioral Health Centers, including peers and family members trained to respond to crises. As one of only 15 grantees nationally, EOHHS is leading the way in improving these important services. 

The Abt team’s self-paced training and virtual webinar events focus on topics such as de-escalation, crisis intervention for youth, and promoting workplace wellbeing. We also developed toolkits to support clinicians leading peer-to-peer events. Toolkits enable clinicians to conduct experiential learning through role play and skills-based behavioral rehearsals. We created job aids to address a range of topics such as autism spectrum disorder, self-injury, trauma-informed interventions, motivational interviewing, and post-stabilization follow-up. 

A key part of developing the material was input from the clinical staff at Behavioral Health Network, a regional crisis service provider in Massachusetts and partner on the project. Their expertise and lived experience ensured that the learning materials were relevant and accurate. We also pilot-tested one of our initial training sessions with nearly 100 MCI staff. Using a survey and participation incentive, we were able to collect feedback and incorporate their suggestions in the final products. 

In addition, we focused on equity by engaging a reviewer skilled in assessing products for equity content and incorporating discussions of racism, systematic oppression, and how these experiences affect mental health and individuals’ access to services. We also used American Sign Language interpreters and live captioning for webinar events.  

Because of our efforts, we consistently received positive feedback from stakeholders. Our MCI leadership spoke very positively about [Abt’s] MCI training that recently rolled out,” says a vice president of a Massachusetts community behavioral health organization. As seasoned Emergency Services/MCI managers, they felt the content very thoroughly and thoughtfully covered foundational concepts in a very efficient way. They heard positive feedback from new MCI staff and seasoned staff alike.”  

All participants who completed a satisfaction survey after attending our two virtual webinar events agreed or strongly agreed that attending was a good use of their time and that they would be able to apply what they learned to their work. As people continue to access these resources, it’s more likely that Massachusetts residents in crisis will get the right help at the right time in the right place.

PROJECT: MassHealth Crisis Intervention Training and Technical Assistance for Emergency Services Programs and Mobile Crisis Intervention Providers
CLIENT: Massachusetts Executive Office of Health and Human Services

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Improving Quality of Care for Cancer Patients in the U.S.

When a cancer patient on chemotherapy missed several appointments and was hospitalized repeatedly, a social worker at the patient’s cancer clinic decided to investigate. It turned out that the patient had no car, lived alone, and had trouble paying for taxi rides to the clinic, 30 miles from his home. He relied on his closest hospital emergency department when his nausea led to dehydration, and emergency department (ED) staff often admitted him to the hospital.  

When the clinic’s oncology team met for one of its frequent huddles as part of its coordinated care effort, the team discussed the transportation challenges. The oncologist described a more potent, though more costly, anti-nausea drug. And the financial counselor found foundation support to cover the higher drug copays. The result: lower costs through avoidance of expensive ED visits and hospital admissions and better care at no additional cost to the patient. 

The incident was not enough to make a major dent in overall Medicare costs in the U.S., but is an example of how lower costs don’t have to conflict with high quality of care. That’s one of the lessons from Abt’s evaluation of the Centers for Medicare and Medicaid Services’ (CMS) innovative Oncology Care Model (OCM), which covers care for Medicare beneficiaries undergoing chemotherapy.

Cancer is the second leading cause of death in the U.S., resulting in more than 600,000 deaths annually. An estimated 1.9 million individuals were diagnosed with cancer in 2022. With the median age of patients 66, Medicare covers a big proportion of care, which was estimated at $200 billion in 2020 and is expected to rise to $246 billion by 2030. And chemotherapy is likely the costliest treatment component, with some new treatments costing more than $10,000 a month.

CMS launched OCM to assess whether investing in higher-quality care for oncology patients would help mitigate rising costs of cancer care. Under OCM, oncology practices were able to bill Medicare for enhanced oncology services for a chemotherapy episode. An episode includes all payments for health services provided during a six-month period, starting when patients begin chemotherapy. CMS made performance-based payments if practices met cost and quality goals.

Abt’s evaluation of the model found that patient care ratings of their cancer care teams began at a high nine out of 10, and that the high levels were sustained amid other changes during OCM’s six-year span. For example, practices reported increased activity in screening for pain and depression. The study found statistically significant cost savings for Medicare, though not enough to cover the costs of the new payments under OCM (for enhanced oncology services and performance-based payments) to the approximately 200 oncology practices that participated in the model. 

“The return on investment [from OCM] is not necessarily monetary,” says one participating oncologist. “It’s the satisfaction of high-quality care and sense of pride that we have an organization that can provide for patients in every way.”

Participating oncology practices transformed their practices to be more person-centered, with 60 percent of practices surveyed describing OCM as an opportunity and impetus to make meaningful improvements:

  • Better and faster access to clinicians, including a dedicated phone line, especially for supportive care (e.g., pain, nausea, other side effects)
  • Reorganized care teams, workflows, and communication to support patients more holistically
  • Patient navigation through confusing treatment protocols
  • Attention to psychosocial needs, pain, and depression
  • Person-centered end-of-life care
  • Expanded same-day and after-hours supportive care
  • More financial counseling about treatment plans, out-of-pocket costs, and resources to cover them.

The evaluation’s equity analyses showed that the proportion of low-income patients treated under OCM didn’t drop over time. This meant the models didn’t avoid low-income patients to increase the odds of success, despite incentives to do so. Evidence also indicated that adherence to high-cost drugs improved for historically underserved populations; better financial counseling and connections to resources may have been the reason.

Our evaluation also showed that total episode payments rose 23.8 percent overall between 2015 and 2020. But OCM payments increased more slowly, by 21.8 percent. This translated into a savings of $499 per episode.

High-risk cancers are where the greatest reductions in total episode payments occurred. Savings amounted to $1,092 for lung cancer total episode payment, about $1,531 for lymphoma,  $1,166 for high-risk breast cancer, and $1,290 for colorectal/small intestine cancer. Our finding that practices achieved the biggest impacts on certain high-volume, high-risk cancers helped inform the design of CMS’ new Enhancing Oncology Model, which launches this summer. It focuses on seven high-risk types of cancer instead of the more than 20 included in OCM.

More work remains to improve quality and rein in costs for cancer care. Abt's mix of qualitative and quantitative analysis provides policymakers with the insights needed to refine future cancer-care models. And that might bring us ever closer to achieving those goals.

LEARN MORE: Analyzing If An Oncology Care Model Will Improve Care and Lower Costs
PROJECT: Evaluation of the Oncology Care Model
CLIENT: U.S. Centers for Medicare & Medicaid Services

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Responding to Emerging Malaria Risks

Combatting malaria requires scientific sleuthing. It’s what helped mortality from malaria drop 36 percent between 2010 and 2020. But the number of deaths worldwide still exceeds 600,000 a year. And 3.2 billion people remain at risk. So the scientific inquiry—entomology—has to continue.

For a decade we have worked in dozens of countries on three continents to protect people from malaria through the delivery of life-saving mosquito, or “vector,” control interventions, like insecticide-treated nets and indoor residual spraying (IRS). In the past year alone, we protected 17.6 million people under the President’s Malaria Initiative’s (PMI) VectorLink project.

Abt is also at the cutting edge of the mosquito detective work. A lot of factors—rainfall, temperature, humidity—influence mosquito density, longevity and malaria transmission risk. Insecticide resistance poses a challenge. So does the interplay between human behavior and mosquito behavior. That’s why malaria control programs need to tailor mosquito control approaches to meet different communities’ needs.

Now we are facing a new threat. In 2019, the World Health Organization issued an initial vector alert, updated in 2023, about the invasion and spread of Anopheles stephensi in Africa, an efficient malaria vector. This menacing mosquito thrives in urban environments, putting millions at risk. The WHO urged countries to enhance their surveillance to be able to monitor this mosquito’s presence and spread. Abt was already doing so: When An. stephensi was first found in Ethiopia in 2016, Abt was already there as a key partner for surveillance and risk modeling.

As this grave risk in Ethiopia increased, PMI asked Abt to figure out how to protect communities that might be affected. But the core vector control interventions that we implement in other geographic areas of Ethiopia are not the best options for this mosquito. That’s because the majority of An. stephensi mosquitoes don’t rest indoors like other malaria vectors do, so IRS might not kill them. They also bite early in the evening, before people go to sleep, so bed nets might not offer adequate protection.

But while An. stephensi behavior is not amenable for vector control interventions that target the adult mosquito, other vector control options that target the aquatic stage could work. And Abt was prepared. In 2022, we worked quickly with the Ethiopia National Malaria Program and PMI to launch a targeted larval source management program in several urban communities where malaria risks were increasing. This activity focused on quickly finding mosquito breeding sites preferred by An. stephensi—mostly manmade containers that can hold water like jerry cans, buckets, cisterns, barrels and old tires—and addressing them. We mobilize households to get rid of containers where these mosquitoes might breed, a process called source reduction. And we use a biological larvicide (safe for humans) to treat water containers that can’t be discarded or that households need to keep. It kills the mosquito larvae before they can turn into adult mosquitoes, a process known as larviciding.

properties covered
potential breeding sites eliminated
containers treated with larvicide

We work with communities and the local government to make our approach effective. We set a goal of hiring at least 50 percent women and achieved it. We collaborated with local leaders to hire people from the community where we are supporting larval source management. Homeowners are more receptive to community members rather than strangers coming into their homes.

The good news is that the data show that over time, larval and pupal density have dropped. This means fewer immature mosquitos are making it to adulthood where they can infect people. But unanswered questions remain. For example, other factors, like environment or weather, could have played a role in the density reduction. But it’s likely the intervention was effective because through our surveillance, we found higher larval densities in nearby locations where there was no intervention.

Has larval source management reduced malaria cases and mortality, the ultimate goal? It's too soon to tell. However, our work in Ethiopia is paving the way for the global response to An. stephensi, which is critical, considering some estimate this mosquito has the potential to put upwards of 120 million additional people at risk of the disease.

That’s not the end of our sleuthing. PMI VectorLink conducted modeling to predict where the vector’s presence could spread from the areas in Ethiopia that provide a suitable climate for its survival. The modeling will have to evolve as the mosquito’s behavior changes, particularly because this mosquito species is adaptable and might continue to change. “That’s why this vector is such a challenge,” says Matt Kirby, PMI VectorLink Entomology Director. “It’s less predictable than the more established malaria vectors in Africa.”

Our entomologists worldwide are on the case, keeping tabs on this new threat with national malaria programs in dozens of countries under PMI VectorLink and the new PMI Evolve project. And we will adapt our approaches as needed to protect communities and make further progress toward eliminating the malaria scourge.

LEARN MORE: Climate Change, Malaria, & Data: Getting Ahead of the Spread | Spotlight On: Climate and Health
PROJECT: U.S. President’s Malaria Initiative VectorLink Project
CLIENT: U.S. Agency for International Development (USAID)

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