The operating room (OR) is the most resource-intensive setting in the hospital, making accurate OR financial metrics essential for value-based initiatives and cost-effectiveness analyses. However, prior estimates of OR time have been rendered likely obsolete by the COVID-19 pandemic, sustained inflation, and hospital consolidation, and conflation of 3 financial parameters-costs, charges, and revenue-has led to misapplication of these estimates. To estimate the cost of 1 minute of OR time in California hospitals, assess trends over time by hospital ownership and teaching status, and provide benchmarks for OR charges and revenue. This longitudinal cross-sectional study examined California Hospital Annual Disclosure Reports for fiscal years (FYs) 2014 to 2022 from short-term general and specialty care hospitals in California. Data were analyzed from January 24 to March 13, 2026. The primary outcome was mean costs, charges, and revenue per minute of OR time, stratified by hospital ownership and teaching status. Costs were further divided into direct and indirect components. Descriptive statistics summarized hospital characteristics and financial measures. The study included 278 hospitals that provided California Hospital Annual Disclosure Reports for FY 2022. Of these, 164 (59.0%) were not-for-profit hospitals, 75 (27.0%) were for-profit hospitals, and 39 (14.0%) were government owned hospitals; 34 (12.2%) were teaching hospitals. The mean (SD) cost of OR time across all hospitals was $57.71/min ($24.09/min), representing a 54% increase from FY 2014 with an annual increase of 5.24% (95% CI, 4.63%-5.82%). Direct costs accounted for 56.6% of total costs ($32.56 of $57.53), with wages and benefits comprising approximately two-thirds of direct costs. The mean (SD) charge was $295.09/min ($148.23/min) and the mean (SD) revenue was $66.31/min ($31.30/min). Government-owned hospitals had the lowest charges, highest costs, and intermediate revenues, illustrating that these 3 measures are not interchangeable. In this cross-sectional study, the mean cost of OR time in California hospitals was $57.71/min in FY 2022, establishing an updated benchmark for surgical cost analyses. Additionally, benchmarks were established for OR revenue ($66/min) and charges ($295/min). Appropriate use of the different financial metrics along with accurate values is essential for valid cost-effectiveness analyses and value-based surgical care initiatives.
The objective of this study was to characterize the trade-off between milk revenue and conception costs and to identify body condition score (BCS) profiles during lactation that jointly maximize milk revenue while minimizing conception costs in dairy cows by using the Non Dominated Sorting Genetic Algorithm II (NSGA II). A retrospective observational analysis was performed using milk yield, monthly average values from daily BCS automatically recorded after every milking, and fertility records from 12,042 lactations of 7,626 Holstein cows from a commercial dairy farm located in Colorado, USA. Overall, lower BCS was associated with greater milk yield, whereas higher BCS was associated with improved fertility, as indicated by shorter calving to conception intervals, and greater pregnancy probability. In addition, we identified BCS at nadir (nBCS; the lowest body condition score observed during lactation) and monthly BCS values across the first 10 mo of lactation that consistent with efficient outcomes within a lactation, rather than a single optimal trajectory. The NSGA-II analyses revealed that increased milk revenue often comes at the expense of higher costs from delayed conception. Nevertheless, overall profitability is primarily driven by revenue gains from milk production. The monthly BCS average for the most profitable BCS values ranged from 2.50 to 3.27. These scores were relatively lower compared with the least profitable solutions that preserved BCS and had lower delayed conception costs. Consequently, net profit (milk yield revenue - cost of delayed conception) for the most profitable solutions exceeded the least profitable by $1,254, $1,500, $979, and $1,140 per lactation in parity 1 through 4, respectively. The pareto frontier generated by NSGA-II offers a menu of strategies, from high yield options that accept greater conception costs to balanced approaches that safeguard fertility and herd productivity. These data driven insights advance the use of 2 sourced of highly frequent data points measured at dairy farms (individual milk yield and automated BCS) by integrating economic modeling with biological performance metrics, enabling profit oriented BCS management tailored to lactation stage and economic priorities.
The illicit drug trade generates billions of dollars in revenue per year, much of which comes from wholesale and retail sales late in the supply chain. Yet, the methods retailers and low-level wholesalers use to launder this revenue remain poorly understood. Using in-depth interviews with illicit drug entrepreneurs in the United States and the United Kingdom, this article analyses laundering strategies among such market actors. Our findings indicate that a significant proportion of their illicit proceeds are disposed of through relatively small-scale 'everyday' cash transactions (< $1,000) that are effectively untraceable. For those generating more substantial revenues, a variety of accessible and uncomplicated laundering strategies are employed, such as reporting such revenues as taxable income, using proxies to launder funds, and using revenues as investment capital within small-scale legal enterprise. Ultimately, we identify uncomplicated, yet largely effective, methods of laundering criminal proceeds amongst our sample of low- to medium-level illicit drug sellers. Though the sums at an individual level are relatively trivial, the 'mass of minor offences' of this nature likely accounts for a significant share of laundered drug revenues in Western consumer drug markets.
Automated milking systems (AMS) allow cows to be milked voluntarily, resulting in a wide variation in milking frequency, particularly during early lactation. This study aims to understand the relationship between milk yield, revenue and milking frequency in guided-flow AMS, with emphasis on cows achieving at least 3 milkings per day (3X) after 21 d in milk (DIM). Daily cow-level data were collected from 5 commercial Wisconsin herds, covering July to December 2024, and analyzed using 4 econometric models. First, we characterized the relationship between daily milking frequency and milk yield across lactation. Milk yield increased with milking frequency, but with diminishing marginal returns. Second, we compared milk yield and revenue from d 22 to d 150 for cows averaging ≥3X by d 22 of lactation and those below this threshold. Cows that reached early 3X averaged 2.7 kg/d more milk per day and generated 5.4% higher mean milk revenue at US all-milk prices from July 2022 to December 2024. For one dairy farm with detailed milk composition records, early 3X cows had higher yields of milkfat, protein, and other solids and lower SCC, increasing mean milk revenue by $1.40/cow/d. These findings suggest a positive association between milking frequency, production, and milk revenue in AMS herds.
The expansion of recovery support services, such as recovery housing, is critical to continue to meet the needs of individuals with substance use disorder. Many unknowns exist regarding the business operations of the recovery housing industry. This study aims to estimate the annual operating costs, cost components, and revenue sources of recovery housing using data from a national survey. A cross-sectional survey was employed to assess the financial landscape of a national convenience sample of recovery housing organizations, including their annual operation costs, cost categories, and revenue sources. Data from 408 recovery housing organizations operating 1458 residences were collected between January 2024 and February 2025 through a survey of recovery houses in 19 states. The survey yielded a response rate of 46% of residences in participating states. Of the 265 recovery housing organizations that provided annual estimated operating costs, the median annual operating cost of recovery housing organizations in 2023 was $155 000 (average of $420 716), ranging from $1500 to $20.5 million. The median annual cost per resident served annually was $6464 (average of $12 172). Most costs for recovery housing organizations were related to operational costs, including property costs and staffing costs. Resident fees were, on average, the largest source of revenue for recovery housing organizations, yet most organizations reported they did not receive all resident fees charged. Recovery housing organizations are diverse in terms of their operational cost makeup and service mix. Compared to other recovery support services and treatment modalities, recovery housing operates at a relatively low cost per resident served.
Uganda faces a rising burden of noncommunicable diseases (NCDs) at a time when pressure to mobilize domestic health financing is increasing. These challenges have become more acute since January 2025, when geopolitical shifts and donor fiscal tightening led to substantial reductions in external health funding. Consequently, policymakers have renewed interest in health taxes as a mechanism both to reduce consumption of harmful products and generate domestic revenue for health. While tobacco taxation has received sustained policy attention, largely due to the influence of the WHO Framework Convention on Tobacco Control, considerably less is known about the political dynamics shaping alcohol and sugar-sweetened beverage (SSB) taxation. This study therefore examines the factors contributing to the relatively low prioritization of alcohol and SSB taxes within Uganda's policy agenda. Guided by the framework on political priority, we conducted 25 semi-structured interviews with stakeholders from government, parliament, civil society, academia, industry, and the media. We also reviewed 22 documents from 2015 to 2025, including policy papers, fiscal records, parliamentary debates, and industry materials. We analyzed the data thematically following an inductive thematic analysis approach. Coding was informed by the framework and strengthened through triangulation across interviews and documentary sources to enhance credibility. We identified three levels of barriers. First, transnational norms promoted health taxes, but regional tax harmonization commitments within the East African community constrained national policy space. Second, domestic advocacy was weakened by fragmented ministerial mandates, limited local evidence, retreating policy entrepreneurs, and industry lobbying. Third, within the national political environment, the multiparty legislative dynamics, the high cost of sponsoring private members' bills, and revenue-centric fiscal framing limited traction. The 2025 donor financing contraction acted as a focusing event that revived debate on health taxes primarily as domestic health financing stabilization instruments rather than NCD prevention tools. While policymakers support health taxes to curb NCDs and increase domestic revenues, taxes on alcohol and SSBs remain underprioritized in Uganda due to institutional fragmentation, political-economic incentives, and legislative resource constraints. As external financing declines, it will be essential to strengthen locally grounded evidence, cross-sector coalitions, and integration of health objectives into fiscal reforms. In this way, health taxes represent a durable policy option for quickly mobilizing financial resources for health and preventing NCDs.
As philanthropy becomes an increasingly important revenue source for healthcare institutions, fundraising skills emerge as a crucial competency for executives and administrators, as well as physicians, nurses, researchers, and educators. Despite its significance, healthcare training seldom includes fundraising, and peer-reviewed healthcare literature offers limited guidance. This report aims to provide a practical and ethically and theoretically grounded guide to successful fundraising, with a focus on securing gifts of $1 million or more. We analyzed a major academic hospital system's customer relationship management system and reviewed the growth of the organization's fundraising program. The relevancy of the findings was verified through a review of healthcare, medical, academic, and fundraising publications. We also gathered and contributed personal observations and experiences of the program from executives, physicians, and other healthcare professionals, academics, and fundraisers. Over 21 years (2003-2023), the organization's fundraising program secured more than $1 billion and increased philanthropic revenue from an average of less than $10 million annually to an average of more than $100 million annually. Key components to this growth included: (a) increasing new commitments of $1 million and above from an average of 7.5 annually (2013-2016) to an average of 19 annually (2017-2020) by demonstrating organizational excellence, creating and implementing strategic plans, engaging the president and CEO as a lead fundraiser, and employing matching challenging initiatives; (b) establishing a pipeline of more than 1,000 donors giving $1,000 and above annually; and (c) engaging physicians in the fundraising process while protecting the physician-patient relationship. Informed by these findings and practical examples, current and emerging leaders in healthcare and their fundraising teams can collaboratively evaluate, strengthen, and secure increased philanthropic revenue, including $1 million gifts and higher.
This article comprehensively evaluates the energy, exergy, environmental, and economic performance of a hybrid system integrating a proton exchange membrane (PEM) electrolyzer with an organic Rankine cycle (ORC) driven by flat-plate solar collectors (FPSCs) (224.64 m2) under varying flow rates. Five flow rates were simulated in engineering equation solver (EES), yielding daily electricity outputs between 86.33 MJ and 91.52 MJ, equivalent to 2.676-2.837 GJ throughout July. Hydrogen production ranged from 414.35 to 439.30 g per day, resulting in 12.85-13.62 kg over the month. The highest hourly energy efficiencies varied from 23.82% to 21.71%, while the maximum exergetic efficiencies remained nearly constant at 6.70%-6.72%, indicating stable system behavior. The hybrid setup reduced CO2 emissions by 39.39-42.56 kg per day, totaling 1221.09-1984.31 kg in July. While the financial gain declined marginally as the flow rate increased from 10.90 USD to 10.15 USD per day, corresponding to 337.91-314.57 USD monthly, the system nevertheless indicated considerable operational and ecological advantages. The average monthly electricity generation across the evaluated flow rates was calculated as 1.974 GJ, corresponding to an average monthly revenue of 235.12 USD and an estimated annual revenue of 2,821 USD, with a simple payback period of 9.73 years.
Most US health systems operate on a local or regional scale and face substantial financial and staffing pressures, which are intensified by challenges related to physician satisfaction and difficulties in recruitment and retention. Ambient artificial intelligence (AI) documentation solutions have the potential to reduce burdens and improve satisfaction, but vendor selection is often undermined by cognitive biases, unvalidated marketing claims, and limited real-world testing. To address this, McLeod Health developed and implemented an objective, multiphase approach to evaluate and adopt an ambient AI solution across its multihospital system. Our evaluation process began in spring 2024 with 4 leading vendors tested through live clinical simulations using 15 complex outpatient scripts, with organizational leaders serving as standardized patients. Ambient patient encounters were captured in real time, and AI-generated notes were scored by physicians, revenue cycle experts, and nonclinical reviewers for accuracy, billing quality, and readability. The top 2 vendors advanced to demonstrations of Epic workflow integration, with physician usability feedback guiding the final selection. In the third phase, the chosen vendor underwent a 90-day pilot across 5 ambulatory specialties beginning in October 2024, followed by system-wide implementation in January 2025. Key performance indicators included documentation time, coding, and financial trends, as well as patient and provider satisfaction. All statistical comparisons were 2-sided using a 95% CI. The 3-phase evaluation process resulted in careful vendor selection. The pilot showed a 35.4% decrease in pajama time (P=.054, trend toward significance) and a 28.3% decrease in time in notes (n=23; P<.001). Coding patterns shifted toward higher-complexity visits, with a 3.8% increase in level 4 established patient visits (P=.05), and established patient volumes increased by 8.5%, which was associated with a projected revenue gain of US $2629 per provider per month. Patient satisfaction improved significantly across multiple domains, with large gains in listening, trust, communication, and treatment information (all P<.001). These gains exceeded those of prior system-wide patient satisfaction initiatives. System-wide rollout has achieved 81% adoption, with more than 150,000 notes generated. Our structured, multiphase evaluation process minimized vendor influence and cognitive bias during selection, validated results through real-world clinical testing, and enabled a system-wide rollout. This approach offers a practical framework for nonacademic health systems to objectively assess, implement, and scale ambient AI solutions while preserving fairness, transparency, and measurable value.
Financial challenges in healthcare systems worldwide, especially in low- and middle-income countries like Iran, have increased hospitals' reliance on insurance reimbursements. Unrecognized insurance deductions often cause severe financial shortages, making efficient deduction management crucial. This study aimed to design a hybrid intelligent system for identifying and predicting insurance deductions by combining machine learning and expert system frameworks. A mixed-methods design was applied in four stages. First, a scoping review identified the causes and patterns of insurance deductions. Second, interviews with 15 insurance experts produced a validated checklist and a dataset from inpatient billing records. Third, using the CRISP-DM methodology, machine learning algorithms were developed and tested in SPSS Modeler alongside a fuzzy expert system developed in MATLAB. Finally, the model was validated using the holdout method. Four categories of deduction drivers were identified: service provision, registration errors, document submission issues, and revenue conversion processes. The CHAID decision tree outperformed other algorithms with a 99% precision rate and the lowest Mean Absolute Error (9.43). A brief assessment of potential overfitting was conducted to ensure that the CHAID model's high accuracy was interpreted cautiously and supported by the validation results. The fuzzy expert system with validated rules was adaptable for deduction classification, especially for cases unsuitable for quantitative modeling. The hybrid model improves detection and prevention of deductions, offering actionable insights for hospital administrators, insurers, and policymakers. Its implementation can enhance hospital information systems, streamline claims processing, and optimize revenue management amid financial constraints.
Between 2021 and 2023, the Association of Public Health Laboratories, in collaboration with the US Centers for Disease Control and Prevention in Kenya, initiated a laboratory improvement programme at the Mbagathi Hospital Laboratory by establishing a molecular assay to respond to the SAR-CoV-2 outbreak in the country and a quality management system (QMS) to improve the quality of laboratory services and processes. Interventions were implemented through the procurement of molecular equipment, supplies, and staff capacity development through training and mentorship. Baseline, midterm, and end-term assessments were conducted, and data were collected using the World Health Organization Regional Office for Africa, Stepwise Laboratory Improvement Program Towards Accreditation tool, version 2015. Data were collected, analysed, and presented in graphs and tables. Transitioning to a self-sustaining model requires both financial autonomy and decentralised leadership. Empowering section heads, as quality leads, ensured operational continuity, even during high-pressure outbreaks. However, significant constraints included intermittent reagent stock-outs due to global supply chain disruptions and high personnel workload during peak pandemic waves. These were mitigated through standardised clinic-laboratory communication and prioritised local service contracts for equipment maintenance. To achieve resilient accreditation, public health facilities should move towards integrated financial models that leverage locally generated revenue. Institutionalising QMS within core hospital governance, rather than as a donor-dependent project, is essential for long-term sustainability in resource-constrained settings. While previous literature has established that QMS improves service delivery, our manuscript is unique in providing a documented roadmap for turning a diagnostic laboratory into a revenue-generating entity that ensures its own supply chain stability. Mbagathi Hospital now serves as a national benchmark, with other county hospitals seeking to emulate its model of efficient resource utilisation.
Using Internal Revenue Service tax return data for 2,366 nonprofit hospitals from the period 2010-23, we examined trends in securities holdings, investment management fees, and investment income volatility. Total securities holdings increased 57 percent to $296 billion, with other securities investments more than doubling. Investment income fluctuated sharply, whereas net patient revenue growth remained near zero, highlighting increasing financial market exposure among nonprofit hospitals.
Efficient utilization of straw resources addresses both resource scarcity and environmental degradation while promoting green development. Despite China's abundant straw resources, uneven spatial distribution and practical challenges in collection, storage, and transportation (CS&T) limit large-scale utilization and pose rural public health risks due to improper disposal. This study integrates government, straw-specialized cooperatives, and farmers into a unified analytical framework and applies evolutionary game theory to examine strategic choices and dynamic interactions among stakeholders in the CS&T process. Key factors analyzed include government regulation costs, subsidy rewards, straw collection and transportation costs, and sales revenues. The results indicate that subsidy rewards and sales revenues are the most significant drivers of stakeholder participation. Moderately increasing subsidies and rewards, while appropriately reducing fines, lowers participation costs for cooperatives and farmers, promoting active involvement and reducing open-air burning. Reducing government regulation costs, improving subsidy allocation accuracy, and moderately increasing fines enhance supervision efficiency. Stakeholder strategies are interconnected in a dynamic feedback system, forming a collaborative cycle of "field collection, centralized storage, standardized transportation, and resource recycling," which improves CS&T efficiency. Long-term policy effectiveness requires a scientifically designed incentive mechanism, with subsidies increased but capped at no more than twice the current standard, balancing motivation, fiscal sustainability, and policy feasibility. This study clarifies multi-stakeholder interaction mechanisms and offers theoretical and practical guidance for optimizing straw resource utilization and strengthening rural public health governance.
Phosphogypsum (PG), the primary by-product of phosphate fertilizer industry, was formerly classified as a hazardous waste, and the most common method of PG management was stacking without further treatment. Global population growth has led to a rapid increase in consumption strategies and affected the balance in global resource recovery. Within the compliance to sustainable development goals and increasing awareness to resource recovery, PG perspective was also irreversibly changed. Global phosphate industry has recognized that PG management is worth from both environmental and financial point of view. Thus, PG is accepted to be a secondary input with high revenue potential. Due to concerns regarding environmental protection, regulations have been more stringent on PG storage and disposal, directing the policies on PG management to circular economy practices. This review provides an insight into regulatory frameworks by country and latest trends on PG management strategies that would support the development of effective resource utilization. Phosphogypsum (PG) is a by‐product of phosphate fertilizer production. For decades, it was mainly stored in large stacks because of concerns about radioactivity and heavy metals. However, growing demand for sustainable resource use has changed this perspective. Many countries now recognize PG as a potential secondary raw material rather than a hazardous waste. This review compares regulatory frameworks in major PG‐producing countries and examines recent research trends. While regulations differ, most focus on safe storage, environmental monitoring, and controlled reuse in agriculture, construction, and road building. Bibliometric analysis shows increasing scientific interest in large‐scale utilization, impurity removal, and environmental risk assessment. The findings highlight the need for clear, harmonized regulations and advanced treatment technologies to support safe and sustainable PG valorization within a circular economy framework.
The decarbonization of urban energy communities increasingly requires coordinated integration of hydrogen, electricity, heat, and mobility under market-regulated environments. This study develops a hydrogen-driven digital transactions market embedded within a clustered, integrated energy hub architecture, where digital transactions markets, such as carbon emission trading (CET) and green certificate trading (GCT) mechanisms, are endogenously incorporated into operational scheduling. The framework coordinates hydrogen-diversified utilization, dual electric-hydrogen transportation systems, multi-vector storage, and renewable generation under carbon accounting constraints and social multi-stakeholder interactions. A decentralized multi-carrier optimization model is formulated to minimize system-wide scheduling cost while integrating CET/GCT revenues directly into dispatch decisions. Uncertainties in renewable generation, demand, and electricity prices are modeled using an inexact probabilistic stochastic programming approach with scenario generation and reduction. To extend evaluation beyond economic performance, a hydrogen-centric eco-social welfare layer comprising ten normalized indicators is introduced, quantifying emission mitigation, accessibility, equity, cost relief, and public acceptance. The model is validated on a four-hub clustered configuration under baseline and stress-test scenarios, including demand surges, renewable shortfalls, hydrogen price shocks, and market price fluctuations. Results demonstrate effective coordination between hydrogen production, storage, and mobility demand, with demand-side flexibility reducing operational costs by more than 16% in selected hubs. Carbon and certificate oracles market participation improves financial performance while enhancing emission compliance. Sensitivity analysis confirms robustness under combined worst-case disturbances. The proposed framework establishes a unified operational market structure that links hydrogen diversification, digital carbon-regulated transactions, and measurable eco-social welfare within sustainable urban energy systems.
Food waste reduction and reutilisation is paramount to meeting national Waste Directives and achieving the Sustainable Development agenda. Implementing Circular Economy principles provides opportunities for cost savings, new revenue streams, and sustainable resource management. Applying the Food Loss and Waste (FLW) Accounting and Reporting Standard, this study identifies and measures sources of FLW in the manufacture of prepared sandwiches, and explores reduction and reutilisation from a Circular Economy perspective. The examined process contributes to circularity, with a loss rate of 13%, of which 97% is valorised. Waste hotspots include product assembly and ingredient preparation, while operational reductions, design changes, and stakeholder collaboration for high-value side-stream management would further reduce FLW impact. Examining a complex food item at the product-level for the first time, this study provides an evidence base for FLW reduction through inventory and hotspot analysis, contextualising the current extent of circularity and suggesting areas for further development.
Behavior changes related to nutrition, physical activity, sleep, alcohol, and smoking are critical for the prevention and management of many chronic diseases, but interventions to implement these behavior changes are operationally and financially challenging to scale in primary care. In an effort to provide broad access to programming that supports such behavior changes for primary care patients, the Massachusetts General Hospital Division of General Internal Medicine developed the Healthy Lifestyle Program, which includes reimbursable virtual shared medical appointment (SMA) programming with health and wellness coaching. The virtual SMAs, also known as group medical visits, launched in 2020 using a secure video platform and initially focused on evidence-based behavior changes to treat chronic diseases such as hypertension and diabetes. The program continued to grow while addressing hurdles in establishing the medical-legal, documentation, and billing requirements for virtual SMAs; sustaining program growth by increasing revenue; building reliable referral and recruitment streams; and expanding offerings to cover more conditions and Spanish-speaking patients. To track the utilization and progress of the program, electronic medical record data were used to measure participation in virtual SMAs and determine predictors of program attrition. In addition, blood pressure (BP) measurements were used to assess clinical outcomes among patients who participated in the hypertension series compared with propensity score-matched controls. Between March 2020 and October 2024, 1679 unique primary care patients attended at least one virtual SMA. Among a cohort of 400 patients referred specifically to the hypertension virtual SMA series, including 200 who attended a virtual SMA and 200 matched control patients who did not schedule a visit, there was a strong trend toward improved BP - without any increase in medications - among virtual SMA participants versus controls (adjusted odds ratio, 1.55; 95% confidence interval [CI], 0.94 to 2.58; P=0.086). In a subgroup analysis of the 87% of the study population whose baseline BP was higher than 130/80 mmHg (n=348, 174 in each group), the intervention group had an 8.7 mmHg decrease in systolic BP compared with a 3.9 mmHg decrease among controls (adjusted difference in systolic BP change, -4.7 mmHg; 95% CI, -8.8 to -0.76; P=0.019). In this subgroup, 33% of those who attended at least one virtual SMA achieved BP control to less than 130/80 mmHg compared with 16% of patients in the control group (95% CI, 7.0 to 27.0). The authors believe that virtual SMAs offer the potential to increase access to reimbursable behavior change interventions in primary care and, as a result, improve chronic disease outcomes.
How Community Health Worker (CHWs) programs are governed shapes their performance. CHW governance can be challenged by CHWs' accountability to both governments and their communities, and the need to coordinate between multiple actors. Furthermore, little is known about how decentralization impacts CHW governance. We examined Nepal's Female community health volunteers (FCHV), where a 2015 constitutional change to federalism-a major governance reform representing one form of decentralization-shifted the responsibility for community health governance to local municipalities. We assessed FCHV governance in the federal landscape and provide preliminary insights into how federalization has impacted FCHV governance in its early years. We identified opportunities and challenges brought by federalization for six actors: federal, provincial and municipal governments, international donors, FCHVs and their representative organizations (unions), and non-governmental organizations. Our qualitative case study comprised 26 semi-structured interviews and five focus groups conducted with FCHVs, health workers, federal and municipal government representatives, researchers, and FCHV union, donor and NGO representatives, across four districts in Bagmati Province, combined with analysis of 259 documents. We analysed these data using a theoretical framework of CHW governance adapted from seven existing frameworks on health workforce and community health governance. We show that FCHV governance was characterized by improved accountability, transparency, participation, and responsiveness to local needs, to some extent. Decentralization remained incomplete, with governance challenged by limited budgetary and administrative decision-space at local levels, in part because of continued central-level control and limited revenue-raising capacity, coordination, and enforcement challenges, as well as lack of role clarity. While donors and NGOs participate in decision-making, FCHVs and their representative organizations are not consistently consulted. The results indicate that strengthening FCHV governance in federal Nepal will require capacity-building of municipalities while loosening the federal grip.
This narrative review examines how government sectors beyond health contribute to the dual goals of equitable obesity prevention and food security through structural, cross‑sector policies. It aimed to synthesise real‑world evidence on the design, implementation and diet‑related impacts of policies across social, education, economic, trade and agricultural, and legal domains. Emerging insights highlight the need for further evaluation of how income supports contribute to diet-related health; the expansion of school meal programs given their multiple co-benefits; the feasibility and impacts of adopting health-promoting taxes that generate public revenue for equity-focused initiatives; how agricultural supports can be repurposed to improve local and equitable food access; and the use of legal instruments to hold food industries accountable and advance public health interests. Coordinated, equitable progress on obesity prevention and food security will require enhanced policy coherence, effective accountability mechanisms, better data on diet and equity outcomes for cross-sector policies, and political commitment to overcome siloed and often unbalanced decision-making processes.
Grid expansion remains a key strategy for increasing electricity access across Sub-Saharan Africa (SSA). However, whether utilities can generate sufficient revenue under current tariffs to support capital investment is unclear. We compile a comprehensive dataset of residential electricity tariffs for 48 SSA countries and develop a standardized model to estimate electricity bills using the Multi-Tier Framework (MTF). Affordability is assessed across income percentiles using simulated income distributions. Under current tariffs, around 608 million people (50%) may not afford Tier 4 electricity, rising to 1.05 billion (85%) for Tier 5 under a 10% energy-poverty threshold. Sensitivity analyses using 5% and 15% thresholds confirm the robustness of these findings. Even where higher-tier electricity is affordable, usage remains low. Combining affordability estimates with utility financial performance, we identify where grid expansion could be viable and where affordability constraints and utility deficits can create electrification traps. In many countries, off-grid solutions may be the only feasible pathway to achieving SDG7.