Breastfeeding (BF) promotion is one of the most cost-effective interventions to advance mother-child health. Evidence-based frameworks and models to promote the effective scale up and sustainability of BF programs are still lacking. A systematic review of peer-reviewed and gray literature reports was conducted to identify key barriers and facilitators for scale up of BF programs in low- and middle-income countries. The review identified BF programs located in 28 countries in Africa, Latin America and the Caribbean, and Asia. Study designs included case studies, qualitative studies, and observational quantitative studies. Only 1 randomized, controlled trial was identified. A total of 22 enabling factors and 15 barriers were mapped into a scale-up framework termed "AIDED" that was used to build the parsimonious breastfeeding gear model (BFGM). Analogous to a well-oiled engine, the BFGM indicates the need for several key "gears" to be working in synchrony and coordination. Evidence-based advocacy is needed to generate the necessary political will to enact legislation and policies to protect, promote, and support BF at the hospital and community levels. This political-policy axis in turn drives the resources needed to support workforce development, program delivery, and promotion. Research and evaluation are needed to sustain the decentralized program coordination "gear" required for goal setting and system feedback. The BFGM helps explain the different levels of performance in national BF outcomes in Mexico and Brazil. Empirical research is recommended to further test the usefulness of the AIDED framework and BFGM for global scaling up of BF programs.

Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.

We summarized the recently published, peer-reviewed literature that examined the impact of investments in social services or investments in integrated models of health care and social services on health outcomes and health care spending. Of 39 articles that met criteria for inclusion in the review, 32 (82%) reported some significant positive effects on either health outcomes (N = 20), health care costs (N = 5), or both (N = 7). Of the remaining 7 (18%) studies, 3 had non-significant results, 2 had mixed results, and 2 had negative results in which the interventions were associated with poorer health outcomes. Our analysis of the literature indicates that several interventions in the areas of housing, income support, nutrition support, and care coordination and community outreach have had positive impact in terms of health improvements or health care spending reductions. These interventions may be of interest to health care policymakers and practitioners seeking to leverage social services to improve health or reduce costs. Further testing of models that achieve better outcomes at less cost is needed.

Although spending rates on health care and social services vary substantially across the states, little is known about the possible association between variation in state-level health outcomes and the allocation of state spending between health care and social services. To estimate that association, we used state-level repeated measures multivariable modeling for the period 2000-09, with region and time fixed effects adjusted for total spending and state demographic and economic characteristics and with one- and two-year lags. We found that states with a higher ratio of social to health spending (calculated as the sum of social service spending and public health spending divided by the sum of Medicare spending and Medicaid spending) had significantly better subsequent health outcomes for the following seven measures: adult obesity; asthma; mentally unhealthy days; days with activity limitations; and mortality rates for lung cancer, acute myocardial infarction, and type 2 diabetes. Our study suggests that broadening the debate beyond what should be spent on health care to include what should be invested in health-not only in health care but also in social services and public health-is warranted.

Despite a renewed focus in the field of global health on strengthening health systems, inadequate attention has been directed to a key ingredient of high-performing health systems: management. We aimed to develop the argument that management -defined here as the process of achieving predetermined objectives through human, financial, and technical resources -is a cross-cutting function necessary for success in all World Health Organization (WHO) building blocks of health systems strengthening. Management within health systems is particularly critical in low-income settings where the efficient use of scarce resources is paramount to attaining health goals. More generally, investments in management capacity may be viewed as a key leverage point in grand strategy, as strong management enables the achievement of large ends with limited means. We also sought to delineate a set of core competencies and identify key roles to be targeted for management capacity building efforts. Several effective examples of management interventions have been described in the research literature. Together, the existing evidence underscores the importance of country ownership of management capacity building efforts, which often challenge the status quo and thus need country leadership to sustain despite inevitable friction. The literature also recognizes that management capacity efforts, as a key ingredient of effective systems change, take time to embed, as new protocols and ways of working become habitual and integrated as standard operating procedures. Despite these challenges, the field of health management as part of global health system strengthening efforts holds promise as a fundamental leverage point for achieving health system performance goals with existing human, technical, and financial resources. The evidence base consistently supports the role of management in performance improvement but would benefit from additional research with improved methodological rigor and longer-time horizon investigations. Meanwhile, greater emphasis on management as a critical element of global health efforts may open new and sustainable avenues for advancing health systems performance.