Pay-for-performance (P4P) programmes are increasingly implemented in healthcare to improve quality of care, but their application in dentistry remains limited. Evidence-based approaches are needed to guide incentive design in value-based dental care, particularly for preventive services, such as topical fluoride application in children. We sought to assess the potential cost-effectiveness of P4P incentives for increasing topical fluoride application among children and to illustrate how simulation modelling can identify conditions under which subgroup-specific incentive levels may be optimal.

We developed and validated a decision-analytic microsimulation model using nationally representative data from the National Health and Nutrition Examination Survey (NHANES 2011–2016) to simulate a cohort of 100 000 US children aged 0–19 years over a 10-year period starting in 2024. The model incorporated heterogeneity in demographic and clinical characteristics to estimate changes in dental caries, quality-adjusted life years (QALYs) and healthcare costs under hypothetical P4P programmes that increased topical fluoride coverage by 2.5% to 50% relative to the baseline rate of 24.5%, with incentive amounts ranging from 2.5% to 50% of provider salary. Sensitivity analyses assessed robustness to variation in key parameters.

Cumulative incidence of dental caries, QALYs, total healthcare costs and incremental cost-effectiveness ratios (ICERs).

Across a broad range of incentive–coverage combinations, P4P incentives were generally cost-effective. For example, a 10% salary-based incentive linked to a 5% relative coverage increase reduced 186.3 cases of tooth decay and yielded 33.8 QALY gains per 10 000 children, resulting in an ICER of $8501 per QALY gained. The intervention was estimated to be cost-saving at coverage increases ≥27.5%. Subgroup analysis indicated larger absolute benefits among racial/ethnic minority children.

P4P incentives to increase topical fluoride application in children could be cost-effective, and potentially cost-saving, under certain conditions. Cost-effectiveness modelling can help define incentive–coverage combinations that are likely to promote both efficiency and equity. Empirical studies are needed to validate provider responsiveness and establish achievable benchmarks for programme design.

Despite global commitments to eliminate malnutrition, over half the world’s population remains affected. Multisectoral nutrition interventions targeting both proximate and distal causes of malnutrition are essential across the lifespan. Yet, current data collection lacks comprehensive nutrition intervention coverage measures, risking inaccuracies in tracking progress. The One Nutrition Coverage Survey (ONCS) aims to test new and refined coverage measurement methods, assess coverage equity and guide integration into large-scale household surveys.

The ONCS will be a cross-sectional, population-representative household survey conducted in four districts of Bangladesh (Rangpur, Sylhet, Dhaka and Khulna), selected for their geographic spread and urban–rural balance. A stratified multistage sampling approach will be used to select enumeration areas, and a total of approximately 3280 households randomly selected within each EA will be included in the survey. The survey will interview women of reproductive age (15–49 years), caregivers of children (0–9 years), adolescents (10–19 years) and pregnant women, collecting data on multisectoral nutrition interventions relevant to these groups. It will use both existing and new measures, while also capturing monetary and non-monetary costs for survey design to implementation. Data will be analysed to assess coverage, co-coverage and equity by sociodemographic characteristics, as well as the feasibility, accuracy and costs of the survey approach.

The study protocol and instruments were reviewed and approved by the International Centre for Diarrhoeal Disease Research, Bangladesh’s (icddr,b) Ethical Review Board in Bangladesh and the International Food Policy Research Institute’s Institutional Review Board in Washington, DC, USA. Adults provided signed informed consent and adolescents their assent. Findings will be shared through peer-reviewed publications, conferences and presentations in Bangladesh with key stakeholders. This study will yield new tools, methods and evidence for measuring multisectoral nutrition intervention coverage, applicable to other low-income and middle-income countries. Learnings from ONCS will enhance data collection aligned with national strategies, helping governments improve coverage assessments, inform decisions and strengthen programme monitoring.